164 Dissociative Identity Disorder (300.14)

The above video about Sybil contains content licensed by Warner Bros. Entertainment

DID, formerly refer to as multiple personality disorder, is characterized by the existence of two or more identities or personality traits within a single individual. Patient with this disorders demonstrate transfer of behavioral control among alter identities either by state transitions or by interference and overlap of alters who manifest themselves simultaneously. It is observed in 1-3% of the general population. (American Psychiatric Association, 2000)

Mental Status

• Patient is alert and oriented in all spheres.
• Affect may be labile or irritable.
• Mood is euthymic or anxious.
• Relatedness is very limited, and eye contact is very frequently minimal.
• Thought content may be characterized significant hypervigilance, preoccupations, or hallucinations.
• Patient appears fixed on extraneous or internal stimuli.
• Reasoning and judgment are diminished and insight is poor.
• An overall increase incidence of both suicidal and homocidal ideation in these patients is present.
• Orientation is frequently off.
• Long-term memory is poor.

The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:

• 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)” (p. 529).
• B. “At least two of these identities or personality states recurrently take control of the person’s behavior” (p. 529).
• C. “Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness” (p. 529).
• 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” (p. 529).

Several symptoms are characteristic:

• Fluctuating symptom pictures
• Fluctuating levels of function from highly effective to disabled
• Severe headaches or other pains
• Time distortions, time lapses, and amnesia
• Depersonalization or derealization occurs when a person feels unattached to him or herself. During this phenomenon, it is almost as if one can see themselves from another view point. Derealization is when one experiences surroundings or people as if they are new, eccentric, or dreamlike when they are clearly not.
• Patients can lose time; they can end up in places and not know how they arrived there or why. They also may find objects that they do not identify or handwriting that they do not think they wrote.
• Individuals with Dissociative Identity Disorder frequently report having experienced severe physical and sexual abuse, especially during childhood. However, each child’s mind can produce distorted images or memories, so it is hard to tell how accurate they are. Some past experiences can be cleared up through objective evidence. Some individuals may have post traumatic symptoms such as nightmares, flashbacks, and startle responses.
• Certain identities can control their pain levels or other physical symptoms, while some individuals will self-mutilate and have suicidal thoughts. They may also experience relationships that contain both sexual and physical abuse. The identities or personality states persistently take control over the person’s behavior. These alternate identities are frequently diverse from the individual’s personality.

Child vs. adult presentation

There are no reliable figures on the diagnosis of children. However, it has increased during the 1990s. A child acting like someone else is perfectly normal. They are trying to get a sense of self. Of course, if some trauma happens in a child’s life, the result may go beyond simply mimicking another person. It may go as far as to creating alternate personality states so they can create a fantasy world in order to escape real life. The average age of onset is in early childhood, generally by the age of four. The average time period for the first symptom to occur to diagnose is 6-7 years. The disorder may go dormant after 40 years of age but may reappear during episodes of stress,trauma or with substance abuse.

Gender and cultural differences in presentation

• Dissociative Identity Disorder has been found in individuals from several different cultures all around the world. It is diagnosed 3 to 9 times more often in adult females than in adult males; in childhood, the female-to-male ratio may be even more, but the data is limited. Males tend to have fewer identities than females. Males have approximately 8 identities. Females tend to have around 15 or more.
• Some researchers report that dissociative symptoms were more common among minorities, but when socioeconomic statues was controlled, that difference disappeared.

Epidemiology

• “The studies do not give an exact estimate, however the numbers have increased drastically. A reason for this is because it could have been misdiagnosed as schizophrenia or bipolar disorders. About 7% of the population may have undiagnosed dissociative disorder. Also, people have become more aware of child sexual abuse, which is a leading cause of DID. DID may be present in about 1% of the general population. India, Switzerland, China, and Germany’s prevalence rates range from 0.015% to 0.9%. The Netherlands is 2%. The U.S. ranges from 6 to 10% and Turkey at the highest with 14%.” (American Psychiatric Association, 2000)
• However, scientists claim that a person having multiple personalities is bizarre, and the support for it is not credible. Some therapists maintain that using hypnosis and frequent prompting of alters bring about the indwelling identities. Even though, some patients do not show symptoms before the treatment has occurred. There is substantial support for the claim that therapists and the media are creating alters rather than discovering them. (American Psychiatric Association, 2000)
• Dissociative Identity Disorder has a course that is chronic and recurrent. On average, the time between the appearance of the first symptoms and diagnosis is six to seven years. There have been reports of episodic and continuous courses. The disorder becomes less noticeable beyond age 40, but it may reemerge during episodes of stress or trauma or with Substance Abuse. (American Psychiatric Association, 2000)
• Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries.

Etiology

• The causes are not yet confirmed, but there are some theoretical predictions of what causes DID. They are overwhelming stress, inadequate childhood nurturing, and the inability to separate recollections with what actually happens. The most common reason is childhood abuse; most of the cases reported deal with abuse. Some children tend to make up “happy places” that they can disappear to, to get away from the violence. If it happens often enough, the children may not be able to tell the difference between the “happy place” and reality. (American Psychiatric Association, 2000)
• Research also shows that a mixture of environmental and biological factors may cause DID. (American Psychiatric Association, 2000)

Etiology Different Diagnosis

It is indicated when diagnosing DID, clinicians should consider other disorders such as dissociative disorder, mood disorder, personality disorder, schizophrenia, seizure disorder, eating disorder, malingering, and factitious disorders. A critical important difference between DID and Schizophrenia is that in schizophrenic people they hear voices within their heads, not from the outside. In addition, clinicians must be must be careful relying on historical references to recognize chronic amnesia, symptoms of PTST, a history of maltreatment, and the presence of alter identities that may allow them to make a diagnosis of DID even if other comorbid disorders are observed. (American Psychiatric Association, 2000)

Indications for hospitalization

The treatment of dissociative disorders is difficult and time-consuming and is mostly enacted via behavioral modifications through outpatient therapy. However, in extreme cases or when physical or emotional harm is imminent, hospitalization may be a required intervention. Some of the indications for inpatient assessment or hospitalization include severe depression over a long period, anxiety and delusion disorders that lead to compulsive acting out of behaviors, cognitive reactions (eg, nightmares, flashbacks), physical reactions, fatigue, and interpersonal reactions (eg, conflict, problems with mood regulation, antisocial behavior, physical aggressiveness, suicidal behavior, traumatic and schizophrenic episodes). The ultimate goal for hospitalization of a patient is to ensure immediacy in restoring safey and stability. The patient remains at risk as long as no change in behavior or in approach for generating behavior modifications to improve response to stress and quality of life occurs.

Empirically supported treatments

• Treatment is done to try to reconnect the different personalities to one functional identity. Sometimes, if that does not work, a clinician may try other treatments to help with the symptoms. Some of the possible treatments are psychotherapy or medications for comorbid disorders such as anxiety and depression. They may benefit from medication that is prescribed for the comorbid disorders such as antidepressants or anti-anxiety medication. They may also do some kind of behavioral therapy. Some may face a longer, slower process which may only help with symptom relief. However, the ones that are still attached to the abusers may have the most difficult time.

• People with DID may also form mutual self-help support groups within larger communities and online communities.

The show, The United States of Tara on Showtime is a show that depicts a woman that deals with Dissociative Identity Disorder.

Tony, in this video, has 53 personalities.

In this video, a therapist talks about a client whose symptoms often caused others to misdiagnose her.

• Each of the videos contains a person with more than one personality, but all of them including Sybil have a personality that knows about all the others and what is going on.

Dissociative Disorders