Dissociative Identity Disorder

Not to be confused with Dissocial personality disorder.
Dissociative identity disorder
Classification and external resources
ICD-10 F44.8
ICD-9 300.14
MeSH D009105

Dissociative identity disorder (DID), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), is a psychiatric diagnosis that describes a condition in which a single person displays multiple distinct identities or personalities (known as alter egos or alters), each with its own pattern of perceiving and interacting with the environment. The diagnosis requires that at least two personalities routinely take control of the individual's behavior with an associated memory loss that goes beyond normal forgetfulness; in addition, symptoms cannot be due to drug use or medical condition. Earlier versions of the DSM named the condition multiple personality disorder (MPD), and the term is still used by the ICD-10.

There is a great deal of controversy surrounding the topic. There are many commonly disputed points about DID. These viewpoints critical of DID can be quite varied, with some taking the position that DID does not actually exist as a valid medical diagnosis, and others who think that DID may exist but is either always or usually an adverse side effect of therapy. DID diagnoses appear to be almost entirely confined to the North American continent,[1][2][3] adding to the possibility that DID may not be a legitimate diagnosis.
Contents


* 1 Controversy
o 1.1 Over-representation in North America
* 2 Classification
* 3 Signs and symptoms
* 4 Causes
o 4.1 Development theory
* 5 Physiological findings
* 6 Diagnosis
* 7 Screening
* 8 Treatment
* 9 Prognosis
* 10 Epidemiology
* 11 History
* 12 Cultural references
* 13 See also
* 14 Notes
* 15 Further reading
* 16 External links
Controversy
Main article: Multiple personality controversy

DID is a controversial diagnosis and condition, with much of the literature on DID being generated and published in North America, to the extent that it was regarded as a phenomenon confined to that continent.[1][2][3] Even within North American psychiatrists there is a lack of consensus regarding the validity of DID.[4][5] Practitioners who do accept DID as a valid disorder have produced an extensive literature with some of the more recent papers originating outside North America. Criticism of the diagnosis continues, with Piper and Merskey describing it as a culture-bound and often iatrogenic condition which they believe is in decline.[3][6] There is considerable controversy over the validity of the Multiple personality profile as a diagnosis. Unlike the more empirically verifiable mood and personality disorders, dissociation is primarily subjective for both the patient and the treatment provider. The relationship between dissociation and multiple personality creates conflict regarding the DID diagnosis. While other disorders require a certain amount of subjective interpretation, those disorders more readily present generally accepted, objective symptoms. The controversial nature of the dissociation hypothesis is shown quite clearly by the manner in which the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has addressed, and re-addressed, the categorization over the years.

The second edition of the DSM referred to this diagnostic profile as multiple personality disorder. The third edition grouped MPD in with the other four major dissociative disorders. The current edition, the DSM-IV-TR, categorizes the disorder as dissociative identity disorder (DID). The ICD-10 (International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as multiple personality disorder.

Over-representation in North America

Paris[7] in a review offered three possible causes for the sudden increase in people diagnosed with DID:

1. The result of therapist suggestions to suggestible people, much as Charcot's hysterics acted in accordance with his expectations.
2. Psychiatrists' past failure to recognize dissociation being redressed by new training and knowledge.
3. Dissociative phenomena are actually increasing, but this increase only represents a new form of an old and protean entity: "hysteria".

Paris believes that the first possible cause is the most likely.

The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the patient, or a case of unconscious collusion on the part of the patient and the professional is considerable. Unlike other diagnostic categorizations, there is very little in the way of objective, quantifiable evidence for describing the disorder.

The main points of disagreement are these:

1. Whether DID is a real disorder or just a fad.
2. If it is real, is the appearance of multiple personalities real or delusional?
3. If it is real, whether it should it be defined in psychoanalytic terms.
4. Whether it can, or should, be cured.
5. Who should primarily define the experience—therapists, or those who believe that they have multiple personalities.

Skeptics claim that people who present with the appearance of alleged multiple personality may have learned to exhibit the symptoms in return for social reinforcement. One case cited as an example for this viewpoint is the "Sybil" case, popularized by the news media. Psychiatrist Herbert Spiegel stated that "Sybil" had been provided with the idea of multiple personalities by her treating psychiatrist, Cornelia Wilbur, to describe states of feeling with which she was unfamiliar.

One of the primary reasons for the ongoing recategorization of this condition is that there were once so few documented cases (research in 1944 showed only 76[8]) of what was once referred to as multiple personality. Dissociation is recognized as a symptomatic presentation in response to trauma, extreme emotional stress, and, as noted, in association with emotional dysregulation and borderline personality disorder[9].

Classification

The DSM-II used the term multiple personality disorder, the DSM-III grouped the diagnosis with the other four major dissociative disorders, and the DSM-IV-TR categorizes it as dissociative identity disorder. The ICD-10 continues to list the condition as multiple personality disorder. Some believe that DID should not be re-classified as a trauma disorder.[10]
Signs and symptoms

Individuals diagnosed with DID demonstrate a variety of symptoms with wide fluctuations across time; functioning can vary from severe impairment in daily functioning to normal or high abilities. Symptoms can include:[11]

* multiple mannerisms, attitudes and beliefs that are dissimilar to each other
* headaches and other body pains
* distortion or loss of subjective time
* depersonalization
* amnesia
* depression

Patients may experience an extremely broad array of other symptoms that resemble epilepsy, schizophrenia, anxiety disorders, mood disorders, post traumatic stress disorder, personality disorders, and eating disorders.[11]
Causes

The causes of dissociative identity disorder have not been identified, but are theoretically linked with the interaction of overwhelming stress, traumatic antecedents,[10] insufficient childhood nurturing, and an innate ability to dissociate memories or experiences from consciousness.[11] A high percentage of patients report child abuse.[12][13]

Others believe that the symptoms of DID are created iatrogenically by therapists using certain treatment techniques with suggestible patients,[13][3][6][14] but this idea is not universally accepted.[15][12][16][17][18][19] Support for the iatrogenic nature of DID comes from observations that a small number of therapists are responsible for diagnosing the majority of individuals with DID; that patients do not report sexual abuse or manifest alters until after treatment has begun; and the alternative explanation of the "alters" being rule-governed social roles rather than separate personalities.[14]

Development theory

It has been theorized that severe sexual, physical, or psychological trauma in childhood predisposes an individual to the development of DID. The steps in the development of a dissociative identity are theorized to be as follows:

* The child is harmed by a trusted caregiver (parent, guardian) and splits off the awareness and memory of the traumatic event to survive in the relationship.
* The memories and feelings go into the subconscious and are experienced later in the form of a separate personality.
* The process happens repeatedly at different times so that different personalities develop, containing different memories and performing different functions that are helpful or destructive.
* Dissociation becomes a coping mechanism for the individual when faced with further stressful situations.[20]

Physiological findings

Reviews of the literature have discussed the findings of various psychophysiologic investigations of DID.[21][22] Many of the investigations include testing and observation in the one person but with different alters. Different alter states have shown distinct physiological markers[23] and some EEG studies have shown distinct differences between alters in some subjects,[24][25] while other subjects' patterns were consistent across alters.[26] Another study concluded that the differences involved intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of people diagnosed with DID.[27] Brain imaging studies have corroborated the transitions of identity in some DID sufferers.[28] A link between epilepsy and DID has been postulated but this is disputed.[29][30] Some brain imaging studies have shown differing cerebral blood flow with different alters,[31][32][33] and distinct differences overall between subjects with DID and a healthy control group.[34] A different imaging study showed that findings of smaller hippocampal volumes in patients with a history of exposure to traumatic stress and an accompanying stress-related psychiatric disorder were also demonstrated in DID.[35] This study also found smaller amygdala volumes. Studies have demonstrated various changes in visual parameters between alters.[36][37][38] One twin study showed hereditable factors were present in DID.[39]

Diagnosis

The diagnostic criteria in section 300.14 (dissociative disorders) of the DSM-IV require:

* The presence of two or more distinct identity 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). In children, the symptoms are not attributable to imaginary playmates or other fantasy play.[40] A patient history, x-rays, blood tests, and other procedures can be used to eliminate the possibility that symptoms are due to traumatic brain injury, medication, sleep deprivation, or intoxicants, all of which can mimic symptoms of DID.[41]

Diagnosis should be performed by a psychiatrist or psychologist who may use specially designed interviews (such as the SCID-D) and personality assessment tools to evaluate a person for a dissociative disorder.[41]

The psychiatric history of individuals diagnosed with DID frequently contain multiple previous diagnoses of various mental disorders and treatment failures.
Screening

The SCID-D[42] may be used to make a diagnosis. This interview takes about 30 to 90 minutes depending on the subject's experiences.

The Dissociative Disorders Interview Schedule (DDIS)[43] is a highly structured interview which discriminates between various DSM-IV diagnoses. The DDIS can usually be administered in 30-45 minutes.

The Dissociative Experiences Scale (DES)[44] is a simple, quick, and validated[45] questionnaire that has been widely used to screen for dissociative symptoms. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20[46] and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D[42] diagnoses and a cutoff of 20 missed 25%.[47] The reliability of the DES in non-clinical samples has been questioned.[48] There is also a DES scale for children and DES scale for adolescents. One study argued that old and new trauma may interact, causing higher DID item test scores.[10]
Treatment

Treatment of DID may attempt to reconnect the identities of disparate alters into a single functioning identity. In addition or instead, treatment may focus on symptoms, to relieve the distressing aspects of the condition and ensure the safety of the individual. Treatment methods may include psychotherapy and medications for comorbid disorders.[41] Some behavior therapists initially use behavioral treatments such as only responding to a single identity, and using more traditional therapy once a consistent response is established.[49] It has been stated that treatment recommendations that follow from models that do not believe in the traumatic origins of DID might be harmful due to the fact that they ignore the posttraumatic symptomatology of people with DID.[17]

Prognosis

DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily dissociative symptoms and features of posttraumatic stress disorder normally recover with treatment. Those with comorbid addictions, personality, mood, or eating disorders face a longer, slower, and more complicated recovery process. Individuals still attached to abusers face the poorest prognosis; treatment may be long-term and consist solely of symptom relief rather than personality integration. Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives.[11]
Epidemiology

The DSM does not provide an estimate of incidence; however the number of diagnoses of this condition has risen sharply. A possible explanation for the increase in incidence and prevalence of DID over time is that the condition was misdiagnosed as schizophrenia, bipolar disorder, or other such disorders in the past; another explanation is that an increase in awareness of DID and child sexual abuse has led to earlier, more accurate diagnosis. Other clinicians believe that DID is an iatrogenic condition overdiagnosed in highly suggestive individuals,[40] though there is disagreement over the ability of the condition to be induced by hypnosis.[16][15] Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:
Country ↓ Prevalence ↓ Source study ↓
India 0.015% Adityanjee et al. (1989)[50]
Switzerland 0.05-0.1% Modestin (1992)[51]
China 0.4% Xiao et al. (2006)[52]
Germany 0.9% Gast et al. (2001)[53]
The Netherlands 2% Friedl & Draijer (2000)[54]
U.S. 10% Bliss & Jeppsen (1985)[55]
U.S. 6-8% Ross et al. (1992)[56]
U.S. 6-10% Foote et al. (2006)[47]
Turkey 14% Sar et al. (2007)[57]

Figures from the general population show less diversity:
Country ↓ Prevalence ↓ Source study ↓
Canada 1% Ross (1991)[58]
Turkey (male) 0.4% Akyuz et al. (1999)[59]
Turkey (female) 1.1% Sar et al. (2007)[60]

Dissociative identity disorder is diagnosed in a sizable minority of patients in drug abuse treatment facilities.[13]

History

An intense interest in spiritualism, parapsychology, and hypnosis continued throughout the 19th and early 20th centuries,[2] running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings.[61] Hypnosis, which was pioneered in the late 1700s by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists observed second personalities emerging during hypnosis and wondered how two minds could coexist.[2]

The 19th century saw a number of reported cases of multiple personalities which Rieber[61] estimated would be close to 100. Epilepsy was seen as a factor in some cases[61] and discussion of this connection continues into the present era.[26][30]

By the late 19th century there was a general realization that emotionally traumatic experiences could cause long-term disorders which may manifest with a variety of symptoms.[62] Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation.[63] It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation.[64] One of the first individuals with DID to be scientifically studied was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American neurologist Morton Prince studied Fowler between 1898 and 1904, describing her case study in his 1906 monograph, Dissociation of a Personality.[64] Fowler went on to marry one of her analyst's colleagues.[65]

In the early 20th century interest in dissociation and DID waned for a number of reasons. After Charcot's death in 1893, many of his "hysterical" patients were exposed as frauds and Janet's association with Charcot tarnished his theories of dissociation.[2] Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.[2] Freud, a man who actively promoted his ideas and enlisted the help of others, won out over the "lone wolf" Janet who did not train students in a teaching hospital.[61]

In 1910, Eugen Bleuler introduced the term "schizophrenia" to replace "dementia praecox" and a review of the Index medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia "caught on," especially in the United States.[66] A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.

Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports. Bleuler also included multiple personality in his category of schizophrenia. It was found in the 1980s that DID patients are often misdiagnosed as suffering from schizophrenia.[63]

The public, however, was exposed to psychological ideas which took their interest. Mary Shelley's Frankenstein, Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe, had a formidable impact.[61] In 1957, with the publication of the book The Three Faces of Eve, and the popular movie which followed it, the American public's interest in multiple personality was revived. DID began to emerge as a separate disorder in the 1970s when an initially small number of clinicians worked to re-establish it as a legitimate diagnosis.[63]

In 1974, the highly influential book Sybil was published, and six years later the diagnosis of multiple personality disorder was included in the DSM. As media coverage spiked, diagnoses climbed. There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990.[67] Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995.[68] The majority of diagnoses are made in North America, particularly the United States, and in English-speaking countries more generally[69] with reports recently emerging from other countries.[50][51][52][53][54][57][59]

Cultural references
Main article: Dissociative identity disorder in fiction

See also
Psychology portal

* Dissociation
* Fugue state
* Identity formation
* Psychogenic amnesia
* Splitting (psychology)
Notes

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