Dissociative Identity Disorder
(DID)
Previously known as multiple
personality disorder, dissociative identity disorder (DID) is a
condition in which a person has more than one distinct identity or
personality state. At least two of these personalities repeatedly
assert themselves to control the affected person's behaviour. Each
personality state has a distinct name, past, identity, and
self-image.
Psychiatrists and psychologists use a handbook called the Diagnostic
and Statistical Manual of Mental Disorders , fourth edition text
revision or DSM-IV-TR, to diagnose mental disorders. In this
handbook, DID is classified as a dissociative disorder. Other mental
disorders in this category include depersonalization disorder,
dissociative fugue, and dissociative amnesia. It should be noted,
however, that the nature of DID and even its existence is debated by
psychiatrists and psychologists.
Description
"Dissociation" describes a state in which the integrated functioning
of a person's identity, including consciousness, memory and
awareness of surroundings, is disrupted or eliminated. Dissociation
is a mechanism that allows the mind to separate or compartmentalize
certain memories or thoughts from normal consciousness. These
memories are not erased, but are buried and may resurface at a later
time. Dissociation is related to hypnosis in that hypnotic trance
also involves a temporarily altered state of consciousness.
Dissociation occurs along a continuum or spectrum, and may be mild
and part of the range of normal experience, or may be severe and
pose a problem for the individual experiencing the dissociation. An
example of everyday, mild dissociation is when a person is driving
for a long period on the highway and takes several exits without
remembering them. In severe, impairing dissociation, an individual
experiences a lack of awareness of important aspects of his or her
identity.
The phrase "dissociative identity disorder" replaced "multiple
personality disorder" because the new name emphasizes the disruption
of a person's identity that characterizes the disorder. A person
with the illness is consciously aware of one aspect of his or her
personality or self while being totally unaware of, or dissociated
from, other aspects of it. This is a key feature of the disorder. It
only takes two distinct identities or personality states to qualify
as DID but there have been cases in which 100 distinct alternate
personalities, or alters, were reported. Fifty percent of DID
patients harbour fewer than 11 identities.
because the alters alternate in controlling the patient's
consciousness and behaviour, the affected patient experiences long
gaps in memory- gaps that far exceed typical episodes of forgetting
that occur in those unaffected by DID.
Despite the presence of distinct personalities, in many cases one
primary identity exists. It uses the name the patient was born with
and tends to be quiet, dependent, depressed and guilt-ridden. The
alters have their own names and unique traits. They are
distinguished by different temperaments, likes, dislikes, manners of
expression and even physical characteristics such as posture and
body language. It is not unusual for patients with DID to have
alters of different genders, sexual orientations, ages, or
nationalities. Typically, it takes just seconds for one personality
to replace another but, in rarer instances, the shift can be
gradual. In either case, the emergence of one personality, and the
retreat of another, is often triggered by a stressful event.
People with DID tend to have other severe disorders as well, such as
depression, substance abuse, borderline personality disorder and
eating disorders, among others. The degree of impairment ranges from
mild to severe, and complications may include suicide attempts,
self-mutilation, violence, or drug abuse.
Left untreated, DID can last a lifetime. Treatment for the disorder
consists primarily of individual psychotherapy.
Causes and symptoms
Causes
he severe dissociation that characterizes patients with DID is
currently understood to result from a set of causes:
-
an innate ability to dissociate easily
-
repeated episodes of severe physical or sexual abuse in childhood
-
lack of a supportive or comforting person to counteract abusive relative(s)
-
influence of other relatives with dissociative symptoms or disorders
The primary cause of DID appears to be severe and prolonged trauma
experienced during childhood. This trauma can be associated with
emotional, physical or sexual abuse, or some combination. One theory
is that young children, faced with a routine of torture, sexual
abuse or neglect, dissociate themselves from their trauma by
creating separate identities or personality states. A manufactured
alter may suffer while the primary identity "escapes" the unbearable
experience. Dissociation, which is easy for a young child to
achieve, thus becomes a useful defense. This strategy displaces the
suffering onto another identity. Over time, the child, who on
average is around six years old at the time of the appearance of the
first alter, may create many more.
As stated, there is considerable controversy about the nature, and
even the existence, of dissociative identity disorder. One cause for
the skepticism is the alarming increase in reports of the disorder
since the 1980s. An area of contention is the notion of suppressed
memories, a crucial component in DID. Many experts in memory
research say that it is nearly impossible for anyone to remember
things that happened before the age three, the age when some DID
patients supposedly experience abuse, but the brain's storage,
retrieval, and interpretation of childhood memories are still not
fully understood. The relationship of dissociative disorders to
childhood abuse has led to intense controversy and lawsuits
concerning the accuracy of childhood memories. Because childhood
trauma is a factor in the development of DID, some doctors think it
may be a variation of post-traumatic stress disorder (PTSD). In both
DID and PTSD, dissociation is a prominent mechanism.
Symptoms
The major dissociative symptoms experienced by DID patients are
amnesia, depersonalization, derealization, and identity
disturbances.
· AMNESIA.
Amnesia in DID is marked by gaps in the patient's memory for long
periods of their past, and, in some cases, their entire childhood.
Most DID patients have amnesia, or "lose time," for periods when
another personality is "out." They may report finding items in their
house that they can't remember having purchased, finding notes
written in different handwriting, or other evidence of unexplained
activity.
· DEPERSONALIZATION.
Depersonalization is a dissociative symptom in which the patient
feels that his or her body is unreal, is changing, or is dissolving.
Some DID patients experience depersonalization as feeling to be
outside of their body, or as watching a movie of themselves.
· DEREALIZATION.
Derealization is a dissociative symptom in which the patient
perceives the external environment as unreal. Patients may see
walls, buildings, or other objects as changing in shape, size, or
color. DID patients may fail to recognize relatives or close
friends.
· IDENTITY DISTURBANCES.
Persons suffering from DID usually have a main personality that
psychiatrists refer to as the "host." This is generally not the
person's original personality, but is rather one developed in
response to childhood trauma. It is usually this personality that
seeks psychiatric help. DID patients are often frightened by their
dissociative experiences, which can include losing awareness of
hours or even days, meeting people who claim to know them by another
name, or feeling "out of body."
Psychiatrists refer to the phase of transition between alters as the
"switch." After a switch, people assume whole new physical postures,
voices, and vocabularies. Specific circumstances or stressful
situations may bring out particular identities. Some patients have
histories of erratic performance in school or in their jobs caused
by the emergence of alternate personalities during examinations or
other stressful situations. Each alternate identity takes control
one at a time, denying control to the others. Patients vary with
regard to their alters' awareness of one another. One alter may not
acknowledge the existence of others or it may criticize other
alters. At times during therapy, one alter may allow another to take
control.
Demographics
Studies in North America and Europe indicate that as many as 5% of
patients in psychiatric wards have undiagnosed DID. Partially
hospitalized and out-patients may have an even higher incidence. For
every one man diagnosed with DID, there are eight or nine women.
Among children, boys and girls diagnosed with DID are pretty closely
matched 1:1. No one is sure why this discrepancy between diagnosed
adults and children exists.
Diagnosis
Traumatic stressor: The patient has been exposed to a catastrophic
event involving actual or threatened death or injury, or a serious
physical threat to him- or herself or others. During exposure to the
trauma, the person's emotional response was marked by intense fear,
feelings of helplessness, or horror. In general, stressors caused
intentionally by human beings (genocide, rape, torture, abuse, etc.)
are experienced as more traumatic than accidents, natural disasters,
or "acts of God."
The demonstration of two or more distinct identities or personality
states in an individual. Each separate identity must have its own
way of thinking about, perceiving, relating to and interacting with
the environment and self.
Extended periods of forgetfulness lasting too long to be considered
ordinary forgetfulness.
Determination that the above symptoms are not due to drugs, alcohol
or other substances and that they can't be attributed to any other
general medical condition. It is also necessary to rule out fantasy
play or imaginary friends when considering a diagnosisof DID in a
child.
Proper diagnosis of DID is complicated because some of the symptoms
of DID overlap with symptoms of other mental disorders. Misdiagnoses
are common and include depression, schizophrenia, borderline
personality disorder, somatization disorder, and panic disorder.
Because the extreme dissociative experiences related to this
disorder can be frightening, people with the disorder may go to
emergency rooms or clinics because they fear they are going insane.
When a doctor is evaluating a patient for DID, he or she will first
rule out physical conditions that sometimes produce amnesia,
depersonalization, or derealization. These conditions include head
injuries, brain disease (especially seizure disorders), side effects
from medications, substance abuse or intoxication, AIDS dementia
complex, or recent periods of extreme physical stress and
sleeplessness. In some cases, the doctor may give the patient an
electroencephalograph (EEG) to exclude epilepsy or other seizure
disorders. The physician also must consider whether the patient is
malingering and/or offering fictitious complaints.
If the patient appears to be physically healthy, the doctor will
next rule out psychotic disturbances, including schizophrenia. Many
patients with DID are misdiagnosed as schizophrenic because they may
"hear" their alters "talking" inside their heads. If the doctor
suspects DID, he or she can use a screening test called the
Dissociative Experiences Scale (DES). If the patient has a high
score on this test, he or she can be evaluated further with the
Dissociative Disorders Interview Schedule (DDIS) or the Structured
Clinical Interview for Dissociative Disorders (SCID-D).
Treatments
Treatment of DID may last for five to seven years in adults and
usually requires several different treatment methods.
Psychotherapy.
Ideally, patients with DID should be treated by a therapist with
specialized training in dissociation. This specialized training is
important because the patient's personality switches can be
confusing or startling. In addition, many patients with DID have
hostile or suicidal alter personalities. Most therapists who treat
DID patients have rules or contracts for treatment that include such
issues as the patient's responsibility for his or her safety.
Psychotherapy for DID patients typically has several stages: an
initial phase for uncovering and "mapping" the patient's alters; a
phase of treating the traumatic memories and "fusing" the alters;
and a phase of consolidating the patient's newly integrated
personality.
Most therapists who treat multiples, or DID patients, recommend
further treatment after personality integration, on the grounds that
the patient has not learned the social skills that most people
acquire in adolescence and early adult life. In addition, family
therapy is often recommended to help the patient's family understand
DID and the changes that occur during personality reintegration.
Many DID patients are helped by group therapy as well as individual
treatment, provided that the group is limited to people with
dissociative disorders. DID patients sometimes have setbacks in
mixed therapy groups because other patients are bothered or
frightened by their personality switches.
Medications
Some doctors will prescribe tranquilizers or antidepressants for DID
patients because their alter personalities may have anxiety or mood
disorders. However, other therapists who treat DID patients prefer
to keep medications to a minimum because these patients can easily
become psychologically dependent on drugs. In addition, many DID
patients have at least one alter who abuses drugs or alcohol,
substances which are dangerous in combination with most
tranquilizers.
Hypnosis
While not always necessary, hypnosis (or hypnotherapy) is a standard
method of treatment for DID patients. Hypnosis may help patients
recover repressed ideas and memories. Further, hypnosis can also be
used to control problematic behaviors that many DID patients
exhibit, such as self-mutilation, or eating disorders like bulimia
nervosa. In the later stages of treatment, the therapist may use
hypnosis to "fuse" the alters as part of the patient's personality
integration process.
Prognosis
Unfortunately, no systematic studies of the long-term outcome of DID
currently exist. Some therapists believe that the prognosis for
recovery is excellent for children and good for most adults.
Although treatment takes several years, it is often ultimately
effective. As a general rule, the earlier the patient is diagnosed
and properly treated, the better the prognosis. Patients may find
they are bothered less by symptoms as they advance into middle age,
with some relief beginning to appear in the late 40s. Stress or
substance abuse, however, can cause a relapse of symptoms at any
time.
Prevention
Prevention of DID requires intervention in abusive families and
treating children with dissociative symptoms as early as possible.
Resources
BOOKS
Bray, Deborah. The Dissociative Identity Disorder Source Book.
McGraw-Hill Inc. 2001
Acocella, Joan. Creating Hysteria: Women and Multiple Personality
Disorder.San Francisco, CA: Jossey-Bass Publishers, 1999.
Alderman, Tracy, and Karen Marshall. Amongst Ourselves, A Self-Help
Guide to Living with Dissociative Identity Disorder.Oakland, CA: New
Harbinger Publications, 1998.
American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders.4th edition, text revised. Washington, DC:
American Psychiatric Association, 2000.
Saks, Elyn R., with Stephen H. Behnke. Jekyll on Trial,
Multipersonality Disorder and Criminal Law.New York, NY: New York
University Press, 1997.
PERIODICALS
Gleaves, D. H., M. C. May, and E. Cardena. "An examination of the
diagnostic validity of dissociative identity disorder." Clinical
Psychology Review21, no. 4 (June 2001): 577-608.
Lalonde, J. K., J. I. Hudson, R. A. Gigante, H. G. Pope, Jr.
"Canadian and American psychiatrists' attitudes toward dissociative
disorders diagnoses." Canadian Journal of Psychiatry46, no. 5 (June
2001): 407-12.
ORGANIZATIONS
International Society for the Study of Dissociation, 60 Revere Dr.,
Suite 500, Northbrook, IL 60062. <http://www.issd.org/>.
National Alliance for the Mentally Ill. Colonial Place Three, 2107
Wilson Blvd., Suite 300, Arlington,VA 22021. <http://www.nami.org/helpline/did.html>.
Rebecca J. Frey, Ph.D.
Dean A. Haycock, Ph.D.
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We have members of Kate's Place who suffer from DID.