The Unfolding of Dissociative Identity Disorder

Behaviors are a character of human beings. When a person performs atypical behavior in comparison to the population they may be labelled as crazy. So where do certain behaviors come from? Throughout time, groups of people have proposed several explanations of abnormal behavior in human beings. To begin the process of understanding abnormal behavior came ideas from the supernatural tradition where it was first believed that abnormal behavior occurred from the possession of a person by evil spirits or perhaps that it came from the movement of the stars and moon affecting the body.

Then came the biological tradition, popularized by Hippocrates and later, John P. Gray, who believed that abnormal behavior had a biological origin. Hippocrates viewed the brain to be the seat of wisdom, consciousness, intelligence, and emotion. Therefore disorders involving these functions would logically be located in the brain (Barlow, Durand, Hofmann, 2017). Subsequently came the psychological tradition with multiple views of thought ranging from Sigmund Freud and the psychoanalytic model to Ivan Pavlov and his work on classical conditioning.

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From this history and its multiple views, it would be thought that the origins of abnormal behavior could be locked in. However, that is not the case. This can be seen in dissociative disorders.

Dissociative disorders are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception (Simeon, Abugel, 2006). No disorder of the mind has captured the imagination of the public more than Dissociative Identity Disorder (DID). The phenomenon isn’t new by any means. Dissociative Identity Disorder, previously known as Multiple Personality Disorder, has been of great interest to the public for centuries.

Case histories of DID can be found in literature as far back as the eighteenth century. But the first documented case of DID was in 1584. Though it was not labeled as DID at the time due to beliefs that behaviors associated with DID came from demonic possession. Jeanne Fery, a 25-year-old Dominican Nun, wrote her account of her exorcism, writing a 109-page description and treatment course of symptoms that would match those with DID today. It was believed that she was given to the devil at age 2 due to her father’s curse. Jeanne’s alter identities included Mary Magdalene, who was highly rational and helpful in her treatment, appearing at moments of crisis. Multiple internal 'devils' ' are described as representing the deadly sins. A demon is described as having seduced her with sweets which seemed to preside over her subsequent bizarrely disturbed eating (van der Hart, Lierens, Goodwin, 1996). And several other alters were recorded explaining Jeanne Ferry’s behavior to self-cutting, rage attacks, pseudoseizures, vomiting, and loss of speech. Her alters were associated with various actions, switch features, and changes in knowledge and skills. Following Jeanne Ferry was Sister Benedetta (1623), a woman who was supposedly possessed by three angelic boys. These boys would beat her to cause chronic pain. When they took control of her body, each would speak with a different dialect and tone of voice while using different facial expressions (van der Hart, Lierens, Goodwin, 1996). These were two early cases of behavior that seem to match today's label of Dissociative Identity Disorder.

The first person to be officially diagnosed with Multiple Personality Disorder was Louis Auguste Vivet in 1882, he was also one of the earliest accounts of “male hysteria”. His character would change from impulsive and dangerous to calm and gentle. And it was recorded that he may have had 10 personalities, each of which was different in character, memory, and somatic symptoms. One somatic symptom included paralysis of the legs during one of his alters (Faure, Kersten, Koopman, & Van der Hart, 1997).

The Diagnosis of Dissociative identity disorder soon captured the fascination of the public, after the release of popular books and movies emerged on this topic. The release of The Three Faces of Eve and later Sybil questioned the diagnosis of DID. DID had a history of being mistaken for possession. After such a view was no longer acceptable, those with DID were seen as hysterics. In DSM-II and III (1968-1980) the term Hysterical Neurosis, Dissociative Type was used to diagnose such cases. It described the possible occurrence of alterations in the patient's state of consciousness or identity and included the symptoms of 'amnesia, somnambulism, fugue, and multiple personalities'(2nd ed.; DSM-II). These sets of behaviors then came to be identified as Multiple Personality Disorder in the DSM-IV. And then was finally renamed to Dissociative Identity Disorder in the DSM-V (2013- present). It was renamed because it was judged that there are truly no“multiple” complete personalities. Instead in most cases, only a few characteristics are distinct, as the identities are partially independent (Barlow, Durand, Hofmann, 2017).

Disorders are complicated by a wide range of symptoms that can occur. Disorders try to classify certain behavioral patterns yet, no two cases of Dissociative Identity Disorder are identical. This is in consideration of those who experience DID. There can be an unlimited amount of combinations of DID between the persons alter, symptoms, and outcomes. The average number of alter personalities is reported by clinicians to be around 15. Of the population with DID nine females tend to have it compared to every one male. The emergence of DID has been seen in children of 4 years of age, but DID is approximately identified usually at 7 years of age after the appearance of symptoms. Once started, Dissociative Identity Disorder tends to last a lifetime if left untreated. The amount of alters a person has doesn’t seem to vary a great deal over a person's time, but the frequency of switches between the alters tends to slow down with age. There have been no sufficiently large studies done, but in a study on inpatients DID was estimated to be prevalent in 3%-6% of the North American population and approximately 2% of the population in Holland. Reports for 21 countries have been found on DID, but are primarily viewed as someone experiencing possession (Barlow, Durand, Hofmann, 2017).

Although listed the previously mentioned statistics need to be taken with a grain of salt. Because the valid classification of psychiatric disorders (including Dissociative Identity Disorder) has long been a slippery goal. This is due to trying to find adequate criteria for comparative purposes. Although not horrible it can be seen that DID has had changes in terms of its etiology and how to manage it. One of the diagnostic criteria for DID is that the disturbance must not be a part of normal cultural or religious practices. This raises some concerns because who gets to decide whether the disturbance adequately fits this critique? What culture do you account for? The psychologist doing the diagnosing or the person experiencing the symptoms of DID? This can create problems in reliability as the degree to which it is measured could vary between one psychologist to another. There may also be problems with these statistics regarding validity because they were partially done with self-reporting surveys. This can create inconsistent data and misdiagnosis because DID can present to health professionals with symptoms close to Schizophrenia, borderline personality disorder, or bipolar disorder. It is not until the average age of 28 to 35 years old that a person is accurately diagnosed with Dissociative Identity Disorder (Glaves, May, Cardena, 2001).

Regarding treatment for Dissociative Identity Disorder, improvement can be difficult. With the person’s identity fractured into multiple different pieces, reintegrating the personality becomes challenging. There have been no controlled studies, but there are reported successes using psychotherapy to reintegrate identities. The most common treatment has been those that are successful for Post Traumatic Stress Disorder (PTSD). This involves identifying cues or triggers that provoke memories of trauma or dissociation and trying to neutralize them (Barlow, Durand, Hofmann, 2017). It is deemed necessary that the patient overcomes past events that occur in the patient's mind so that they gain a sense of control, even if they are fabricated memories. For a person to regain control of their mind the therapist carefully helps the patient to visualize and relive the trauma until they realize it is just a past event and that they are safe. This can be hard because some events can be so buried that aspects of a person's past can become consciously unknown to them and the therapist. It also becomes extremely important that the therapist builds trust with the patient as re-emerging memories can further the dissociation as the client can be in vulnerable positions during an alter. Hypnosis has been used to access unconscious memories and medications have been used in combination with therapy. Unfortunately, there is no evidence that hypnosis is necessary for the treatment and there is no indication that medication helps improvement (Barlow, Durand, Hofmann, 2017).

This history of abnormal behavior representing dissociations makes it appear that Dissociative identity disorder is well-grounded. However, that is far from the truth. DID may be one of the most controversial and dangerous diagnoses today (DID or MPD is a Bogus, 2011). The previously mentioned fact that Dissociative Identity Disorder was previously known as Multiple Personality Disorder shows that it is a concept open to debate and is hard to pin down. It is then argued that even if DID is real the diagnostic criteria for it make it hard to ever classify someone with Dissociative Identity Disorder as it can be subjective. The last controversy regards the treatment. Because there are few controlled studies of DID it is hard to confidently say what the effects of treatment are to those who experience DID. It was mentioned that a therapist needs to be careful with the treatment so that a person does not further dissociate. This is alarming because if a person did not fit into the category of DID a therapist could essentially make the patient act and fit more into the category of DID even if the therapist is trying to help the client get better. The result may be a client that has received no benefit from treatment, will further dissociate, and may even be harmed because trying to “recover memories' ' can take a toll on mental health itself.

Behavior is a complicated aspect of human life. It can vary from one culture to another and can have different implications from one culture to another. When a behavior is seen as abnormal and causes distress it becomes classified as a disorder, but a question arises. Is there a legitimate cut off to separate one disorder from another? Dissociative Identity Disorder is a phenomenon in which a person may experience different identities each with their own behavior, tone of voice, and physical gestures. Yet the etiology and specific classification of DID is still unclear and has undergone persistent debate. If we are to accurately diagnose and create classifications of disorders further research and support will need to be done in disorders like Dissociative Identity Disorder.