116 Dissociative Identity Disorder (300.14)

This is a video of a man named Tony who has Dissociative Identity Disorder. It is believed that Tony has 53 or more distinct identities or personality states.

The video above is an interview with former NFL running back Herschel Walker. In the interview he briefly discusses his experience with Dissociative Identity Disorder.

DSM-IV-TR criteria

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.

Associated features

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 and Derealization – Depersonalization occurs when a person feels unattached to him or herself. During this phenomenon, it is almost as if you can see yourself from another view point. Derealization is when you experience 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, children’s minds 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, which 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. Also, it could be of a different name, age, gender, or even race.
• Comorbidity occurs with Post- Traumatic Stress Disorder.

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 alter personality states so they can create a fantasy world in order to escape real life. The average age is in early childhood, generally by the age of four. The average time period for the first symptom to occur to diagnosis is 6-7 years. The disorder may go dormant after 40 years of age but may reappear during episodes of stress or trauma or with substance abuse.

Gender and cultural differences in presentation

Dissociative Identity Disorder has been found in individuals from a 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.

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. 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%.
• 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.

Etiology

The causes are not yet confirmed, but there are some theoretical predictions of what causes DID. They are overwhelming stress, physical and sexual abuse especially in childhood, inadequate childhood nurturing, and the disability 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 that and reality. It is also more common when an individual has biological relatives that also have the disorder.

Empirically supported treatments

Treatment is done to try to reconnect the different personalities to one functional identity. Sometime if that does not work, a clinician may try to do something to help with the symptoms. Some of the things are long-term psychotherapy, cognitive and creative therapies, and medications for comorbid disorders or doing 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. Some medications for Dissociative Identity Disorder are antidepressants, anti-anxiety drugs, or tranquilizers to help reduce the symptoms.

Proposed DSM-5 Changes (dsm5.org)

Dissociative Identity Disorder

A. Disruption of identity characterized by two or more distinct personality states or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others or reported by the patient.
B. Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.
C. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice and 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.

Specify if:

a) With non-epileptic seizures or other conversion symptoms

b) With somatic symptoms that vary across identities (excluding those in specifier a)
The workgroup is still considering whether Criterion C is necessary. The specifiers are still under consideration.

Rationale for Change

A. Clarification of language, including indicating that different states can be reported or observed, reducing use of Dissociative Identity Disorder Not Otherwise Specified. Including Trance and Possession Disorder by mentioning “experience of possession” increases global utility.

B. Noting that amnesia for everyday events is a common feature.
C. This criterion is included in DSM-IV Dissociative Identity Disorder. Including it may help differentiate normative cultural experiences from psychopathology.

D. Addition from DSM-IV Dissociative Trance Disorder to increase cross-cultural applicability

Specifiers:

a) A substantial proportion of patients with Dissociative Identity Disorder have conversion symptoms, which are related to their dissociative disorder and require special clinical attention and treatment.

b) Some Dissociative Identity Disorder patients have dissociative variations in somatic symptoms that require clarification for differential medical diagnosis and treatment.

DSM-5 Changes for Dissociative Disorder not Otherwise Specified (300.15)

This category is for disorders in which the predominant feature is a dissociative symptom (i.e. a subjective loss of integration of information or control over mental processes that, under normal circumstances, are available to conscious awareness or control, including memory, identity, emotion, perception, body representation, motor control, and behavior) that does not meet the criteria for any specific Dissociative Disorder. Examples include:

1. Clinical presentations similar to Dissociative Identity Disorder that fail to meet full criteria for this disorder. Examples include presentations in which a) there are not two or more distinct personality states, or b) amnesia for important personal information does not occur.
2. States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while captive).
3. Dissociative trance, characterized by narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one’s control. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.
4. Loss of consciousness, stupor, or coma not attributable to a general medical condition.
5. Ganser syndrome: the giving of approximate answers to questions (e.g., 2 plus 2 equals 5) when not associated with Dissociative Amnesia.
6. Acute reactions to stressful events, lasting less than one month, that are characterized by mixed dissociative symptoms, such as depersonalization, derealization, amnesia, disruptions of consciousness, and/or stupor that cause marked distress or impairment and are not restricted to the symptoms of another mental disorder, e.g., Acute Stress Disorder, Delirium, or another dissociative disorder.
7. Acute states, lasting less than one month, characterized by mixed dissociative symptoms (e.g., amnesia, dissociative flashbacks, disruptions of consciousness) and psychotic symptoms (e.g., catatonia, auditory or visual hallucinations, delusions, grossly disturbed behavior) that cause marked distress or impairment and do not meet criteria for Acute Stress Disorder, a Psychotic Disorder, Delirium, or another dissociative disorder.

An additional example of acute presentations with mixed dissociative symptoms that do not fulfill criteria for the specified dissociative disorders is being considered for inclusion in Dissociative Disorder Not Otherwise Specified.

Rationale

Changes to be consistent with alterations in Dissociative Identity Disorder and the definition of dissociation.