Dissociative identity disorder

Overview
Dissociative Identity Disorder (DID), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), is a mental condition whereby a single individual evidences two or more distinct identities or personalities, 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 and that there is associated memory loss that goes beyond normal forgetfulness, often referred to as losing time or acute Dissociative Amnesia. The symptoms of DID must not be the direct result of substance abuse or a more general medical condition in order to be diagnosed. DID was originally named Multiple Personality Disorder (MPD), and, as referenced above, that name remains in the International Statistical Classification of Diseases and Related Health Problems. It is also commonly mispronounced "Disassociative Identity Disorder", and the primary symptom erroneously called "disassociation".

This condition is not an equivalent for schizophrenia (DSM-IV Schizophrenia and Other Psychotic Disorders), as is a common misconception. The term schizophrenia comes from root words for "split mind," but refers more to a fracture in the normal functioning of the brain, than the personality.

Dissociation is a demonstrated symptom of several psychiatric disorders, including Borderline Personality Disorder (DSM-IV Personality Disorders 301.83), Post-traumatic stress disorder (DSM-IV Anxiety Disorders 309.81 ), and Complex Post Traumatic Stress Disorder, to name a few.

As a diagnosis, DID remains controversial. For many years DID was regarded as a North American phenomenon  with the bulk of the literature still arising there. However, research demonstrates a lack of consensus belief in the validity of DID amongst North American psychiatrists. 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.

Defining the terms
Dissociation at its simplest means that "two or more mental processes or contents are not associated or integrated." This definition assumes that these elements should normally be associated or integrated in conscious awareness, memory, or identity.

The DSM-IV characterizes dissociation as "disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment" while the ICD-10 defines it as "partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements."

To dissociate is to sever the association of one thing from another.

Multiple personalities occur when the identity of a person dissociates to the extent that they have separate existences with their own "identities, life histories, and enduring patterns of perceiving, thinking about and relating to the environment which is distinct from the habitual personality's mode of being in the world."

Alter derives from alter ego and means one of the individual personalities in a person with multiple personalities. Early literature uses the full term while the later literature uses the word by itself.

Defining the controversy
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 ) 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. Often regarded as a dynamic sub-symptomatology, it has become more frequent as an ancillary diagnosis, rather than a primary diagnosis.

The DSM re-dress
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 MPD 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-dressed, the categorization over the years.

The second edition of the DSM referred to this diagnostic profile as Multiple Personality Disorder. The third edition grouped Multiple Personality Disorder in with the other four major Dissociative Disorders. The current edition, the DSM-IV-TR, categorizes the disorder as Dissociative Identity Disorder. The ICD-10 (International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as Multiple Personality Disorder.

The MPD/DID epidemic in North America
Paris in a review offered four possible causes for the sudden increase in people diagnosed with MPD/DID: Paris opines that the first possible cause is the most likely.
 * 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 recognise 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."
 * 4) Powerful psychosocial forces are changing the psychological balance of individuals so as to make dissociative experiences more common.

Other positions
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 (see Multiple personality controversy). Unlike other diagnostic categorizations, there is very little in the way of objective, quantifiable evidence for describing the disorder. This makes the disorder itself subjective, as well as its diagnosis.

The main points of disagreement are these:


 * 1) Whether MPD/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.

Symptoms
Patients often exhibit a wide array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic, mood psychosis and seizure disorders. Symptoms of this particular disorder can include:
 * depression
 * nightmares
 * anxiety (sweating, rapid pulse, palpitations)
 * phobias
 * panic attacks
 * physical symptoms (severe headaches or other bodily pain)
 * fluctuating levels of function, from highly effective to disabled
 * time distortions, time lapse, and Dissociative Amnesia
 * sexual dysfunction
 * eating disorders
 * post traumatic stress
 * suicidal preoccupations and attempts
 * episodes of self-mutilation
 * psychoactive substance use/abuse

Other symptoms may include: Depersonalization, which refers to feeling unreal, removed from one's self, and detached from one's physical and mental processes. The patient feels like an observer of his life and may actually see himself as if he were watching a movie. Derealization refers to experiencing familiar persons and surroundings as if they were unfamiliar and strange or unreal.

Again, doctors must be careful not to assume that a client has MPD or DID simply because they exhibit some or all of these symptoms. For example, someone may have severe PTSD and self mutilate with suicidal ideas, which are two of the symptoms listed above, but in order for DID to be diagnosed, there must be two or more distinctly present personalities.

Persons with dissociative identity disorder are often told of things they have done but do not remember and of notable changes in their behavior. They may discover objects, productions, or handwriting that they cannot account for or recognize; they may refer to themselves in the first person plural (we) or in the third person (he, she, they); and they may have amnesia for events that occurred between their mid-childhood and early adolescence. Amnesia for earlier events is normal and widespread.

Causes/etiology
Although many experts dispute the existence of this controversial diagnosis, Dissociative Identity Disorder has been attributed by some to the interaction of several factors: overwhelming stress, dissociative capacity (including the ability to uncouple one's memories, perceptions, or identity from conscious awareness), the enlistment of steps in normal developmental processes as defenses, and, during childhood, the lack of sufficient nurturing and compassion in response to hurtful experiences or lack of protection against further overwhelming experiences. Children are not born with a sense of a unified identity &mdash; it develops from many sources and experiences. In overwhelmed children, its development is obstructed, and many parts of what should have blended into a relatively unified identity remain separate. North American studies show that 97 to 98% of adults with dissociative identity disorder report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with dissociative identity disorder and other closely related forms of Dissociative Disorders. Although these data establish childhood abuse as a major cause among North American patients (in some cultures, the consequences of war and disaster play a larger role), they do not mean that all such patients were abused or that all the abuses reported by patients with dissociative identity disorder really happened. Some aspects of some reported abuse experiences may prove to be inaccurate. Also, some patients have not been abused but have experienced an important early loss (such as death of a parent), serious medical illness, or other very stressful events. For example, a patient who required many hospitalizations and operations during childhood may have been severely overwhelmed but not abused, although parents helping people through these times can act as a preventative measure.

Human development requires that children be able to integrate complicated and different types of information and experiences successfully. As children achieve cohesive, complex appreciations of themselves and others, they go through phases in which different perceptions and emotions are kept segregated. Each developmental phase may be used to generate different selves. Not every child who experiences abuse or major loss or trauma has the capacity to develop multiple personalities. Patients with dissociative identity disorder can be easily hypnotized. This capacity, closely related to the capacity to dissociate, is thought to be a factor in the development of the disorder. However, most children who have these capacities also have normal adaptive mechanisms, and most are sufficiently protected and soothed by adults to prevent development of dissociative identity disorder.

Diagnosis
If symptoms seem to be present, the patient should first be evaluated by performing a complete medical history and physical examination. Diagnostic tests, such as X-rays and blood tests may be used to rule out physical illness or medication side effects as the cause of the symptoms. Certain conditions, including brain diseases, head injuries, drug and alcohol intoxication, and sleep deprivation, can lead to symptoms similar to those of Dissociative Disorders, including Dissociative Amnesia.

If no physical illness is found, the patient might be referred to a psychiatrist or psychologist who may use specially designed interviews and personality assessment tools to evaluate a person for a Dissociative Disorder.

Diagnostic criteria (DSM-IV-TR)
In summary, the diagnostic criteria in DSM-IV Dissociative Disorders section 300.14 of the Diagnostic and Statistical Manual of Mental Disorders require the occurrence of two or more personalities within the same individual, each of which during some time in the person's life is able to take control. This must be combined with extensive areas of memory loss that cannot be explained as within normal limits. The symptoms must not be better explained by substance use or another medical condition.

The personalities are often very different in nature and may represent extremes of what is contained in a normal person. Memories may be asymmetrical with dominant identities remembering more than passive identities.

Screening and diagnostic instruments
The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) may be used to make a diagnosis. This interview takes about 30 minutes to 1.5 hours, depending on the subject's experiences.

The Dissociative Disorders Interview Schedule (DDIS) 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) is a simple, quick, and validated 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 and in one study a DES with a cutoff of 30 missed 46% of the positive SCID-D diagnoses and a cutoff of 20 missed 25%. The reliability of the DES in non-clinical samples has been questioned.

Pathophysiology
Reviews of the literature have discussed the findings of various psychophysiologic investigations of DID. Many of the investigations include testing and observation in the one person but with different alters. Different alter states show distinct physiological markers. EEG studies have shown distinct differences between alters, findings another study failed to replicate. 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 persons with multiple personalities and those of normal persons. One EEG study comparing DID with hysteria showed differences between the two diagnoses. A postulated link between epilepsy and DID has been disputed by a number of authors. Some brain imaging studies have shown differing cerebral blood flow with different alters while another has failed to replicate this finding. 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. This study also found smaller amygdala volumes. Studies have demonstrated various changes in visual parameters between alters. One twin study showed hereditable factors were present in DID.

Treatment/management
The most common approach to treatment aims to relieve symptoms, to ensure the safety of the individual, and to reconnect the different identities into one well-functioning identity. There are, however, other equally respected treatment modalities that do not depend upon integrating the separate identities. Treatment also aims to help the person safely express and process painful memories, develop new coping and life skills, restore functioning, and improve relationships. The best treatment approach depends on the individual and the severity of his or her symptoms. Treatment is likely to include some combination of the following methods:


 * Psychotherapy : This kind of therapy for mental and emotional disorders uses psychological techniques designed to encourage communication of conflicts and insight into problems.
 * Cognitive therapy: This type of therapy focuses on changing dysfunctional thinking patterns.
 * Medication: There is no medication to treat the Dissociative Disorders themselves. However, a person with a Dissociative Disorder who also suffers from depression or anxiety might benefit from treatment with a medication such as an antidepressant or anti-anxiety medicine.
 * Family therapy: This kind of therapy helps to educate the family about the disorder and its causes, as well as to help family members recognize symptoms of a recurrence.
 * Expressive therapy such as art therapy or music therapy: These therapies allow the patient to explore and express his or her thoughts and feelings in a safe and creative way.
 * Clinical hypnosis: This is a treatment technique that uses intense relaxation, concentration and focused attention to achieve an altered state of consciousness or awareness
 * Behavior therapy: As an increasing number of therapists view DID as iatrogenic, or caused by reinforcing treatment teams, new approaches have emerged. Current standards of care may involve requiring the patient respond to a single name, and refusing to speak with the patient if she or he is a different sex, age, or person than initially presented. As the patient begins to respond more consistently to a single name, and speak in the first person, more traditional therapy for trauma may begin. Though some dislike this approach or criticize it as disrespectful of the client, it is highly effective, and many published accounts confirm this approach. See Kohlenberg & Tsai's "Functional Analytic Psychotherapy" (1991) for a more detailed explanation of this approach.
 * Ego-state therapy: Ego-state therapy is used to help non-dissociative individuals resolve conflicts among different parts of themselves (i.e. ego states); since DID is an extreme differentiation among ego states, many therapists find the approach useful in working with dissociative clients.

Prognosis
Dissociative Identity Disorder does not disappear suddenly, although its symptoms will change in level of severity. A patient's progress can be divided in three groups. The first group tend to have dissociative and post-traumatic symptoms, function well and recover completely with specific treatment. The second group have dissociative symptoms, usually mixed with symptoms from personality disorders, mood disorders, eating disorders, or substance abuse disorders. Improvement is slower, as treatment may be less successful, longer, and more difficult. The third group have severe comorbid psychopathology, and may be emotionally attached to their supposed abusers. This group requires long-term treatment to manage the symptoms rather than to achieve integration.

Prevention/screening
Strategies to prevent the development of DID depend upon how the etiology of the disorder is perceived. Early childhood trauma is frequently attributed as an etiology of DID, and so from this viewpoint, prevention of childhood trauma should reduce the incidence of DID. Those who believe that DID is often caused by suggestions from the clinician to suggestible people, caution clinicians against contributing to the diagnosis.

Epidemiology
The true prevalence of the disorder is hard to determine. The DSM notes the sharp rise in reported cases and states that, "Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been overdiagnosed in individuals who are highly suggestive." The DSM does not give a figure. Reports in the literature are often given by advocates for the condition and figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries: India (0.015% per year ), Switzerland (0.05%-0.1% ), China (0.4% ), Germany (0.9% ), The Netherlands (2% ), U.S. (6%, Approx., 6-8%, 10% ), and Turkey (14% ). Figures from the general population show less diversity: China (0% ), Turkey (0.4% for a general sample and 1.1% for a female sample ), and Canada (1% ).

History
An intense interest in spiritualism, parapsychology and hypnosis continued throughout the 19th and early 20th centuries, running in parallel with Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings. Hypnosis, which was pioneered in the late 1700s by Mesmer and de Puységur, challenged Locke's association of ideas. Hypnotists observed second personalities emerging during hypnosis and wondered how two minds could coexist. Early cases of what would now be diagnosed as DID appeared at this time and were treated by hypnosis. The 19th century saw a number of increasingly sophisticatedly reported cases of multiple personalities which Rieber estimated would be close to one hundred. Epilepsy was seen as a factor in some cases and discussion of this connection continues into the present era.

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. It was in this climate that Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. Janet as one of Charcot's students took these ideas and went on to developed his own theories of dissociation.

In the early 20th century interest in dissociation and MPD 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. Freud recanted his earlier emphasis on dissociation and childhood trauma. 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. Psychologists found that science was hard to reconcile with a "soul" or an "unconscious". In 1910 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.

The public however were 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 tales by Edgar Allan Poe, had a formidable impact but it was not until the 1957 publication of the book The Three Faces of Eve, and the popular movie which followed it, that the American public's interest in multiple personality was revived. 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 MPD from 1880 to 1979, and 20,000 from 1980 to 1990. Acocella reports that 40,000 cases were diagnosed from 1985 to 1995. The majority of diagnoses are made in North America, particularly the United States, and in English-speaking countries more generally with reports recently emerging from other countries.

In popular culture
DID/MPD is common in pop culture fiction. See DID/MPD in fiction for further information.