Dissociative Identity Disorder (Multiple Personality
Disorder)
Dissociative identity disorder is a rare but real disorder that is the most widely discussed of the dissociative disorders. It involves the “presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relat-ing to, and thinking about the environment and self)” (American Psychiatric Association, 2000). The diagnostic criteria also re-quire that “At least two of these identities or personality states recurrently take control of the person’s behavior” (American Psy-chiatric Association, 2000), and that there be amnesia: “Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness” (American Psychiatric Association, 2000). It is a failure of integration of various aspects of identity and personality structure. Often different relationship styles (dependent versus assertive/aggressive) and mood states (depressed versus hostile) segregate with different identities and personal memories. Such patients may be mystified by events that occurred in another “state”, or by responses of others to them for behavior that occurred in a different “state”. This fragmentation of personality often occurs in response to trauma in childhood, and is perceived by the patient as protective, allowing him or her to tolerate and partially evade chronic abuse. These patients thus view treatment ambivalently as an attempt to deprive them of a defense against attack. They also tend to see others as irrational and unfair, since response to one aspect of their personality fre-quently reflects experience with other aspects. One DID patient (prior to diagnosis) reported puzzlement about accusations by friends and acquaintances that she had made hostile comments for which she had no memory. She would find people angry at her for no reason. Thus their personality fragmentation renders them vulnerable to interpersonal problems yet gives them the belief that they are relatively protected from them.
There are
no convincing studies of the absolute prevalence of DID, although there is
widespread agreement that the number of diagnosed cases has increased
considerably in the USA and some European countries in the past two decades.
Two studies have estimated the prevalence as approximately 1% of psychi-atric
inpatients (Saxe et al., 1993; Ross et al., 1991). Factors that may
account for the increase in the number of true reported cases include 1) more
general awareness of the diagnosis among mental health professionals, 2) the
availability of specific diagnostic cri-teria starting with DSM-III and 3)
reduced misdiagnosis of DID as schizophrenia or borderline personality
disorder.
Other authors attribute the increase in reported cases to social
contagion, hypnotic suggestion and misdiagnosis Pro-ponents of this point of
view argue that these individuals are highly hypnotizable and therefore quite
suggestible. They would therefore be especially vulnerable to direct or
implicit hypnotic suggestion. They note that not infrequently a few specialist
psy-chiatrists make the vast majority of diagnoses. However, it has been
observed that the symptoms of patients diagnosed by spe-cialists in
dissociation do not differ from those of patients diag-nosed by psychiatrists,
psychologists and physicians in more gen-eral practice who diagnose one or two
cases a year. Furthermore, such patients have been noted to persist in
presenting symptoms for an average of 6.5 years before attaining the diagnosis.
They encounter many psychiatrists who are convinced that they do not have DID
and that they have some other disorder, such as schizo-phrenia. Were they so
easily suggestible, it seems likely that they would accept a suggestion that
they have other disorders as well, such as schizophrenia or borderline
personality disorder.
Nonetheless, because these patients are indeed highly hypnotizable and
therefore suggestible, care must be taken in the manner in which the illness is
presented to them. However, it is unlikely that the increased number of cases
currently reported is accounted for by suggestion alone. Reduction in previous
misdi-agnosis and increased recognition of the prevalence and seque-lae of
physical and sexual abuse in childhood are also reasonable explanations.
The disorder is more frequently recognized during childhood but
typically emerges between adolescence and the third decade of life; it rarely
presents as a new disorder after age 40 years, but there is often considerable
delay between initial symptom pres-entation and diagnosis.
Untreated, it is a chronic and recurrent disorder. It rarely remits
spontaneously, but the symptoms may not be evident for certain time periods.
DID has been called “a disease of hidden-ness” (Schacter, 1995). The
dissociation itself hampers self-monitoring and accurate reporting of symptoms
and history. Many patients with the disorder are not fully aware of the extent
of their dissociative symptoms. They may be reluctant to bring up symptoms
because of confusion or shame about the illnessor because they encountered
previous skepticism. Furthermore, because the majority of patients report
histories of sexual and physical abuse, the shame associated with that and fear
of retribu-tion may inhibit reporting of symptoms as well.
The major comorbid psychiatric illnesses are the depressive disorders,
substance use disorders and borderline personality disorder. Sexual, eating,
and sleep disorders cooccur less com-monly. Such patients frequently display
self-mutilative behavior, impulsiveness, and overvaluing and devaluing of
relationships. Indeed, approximately a third of patients with DID have
symp-toms that fit criteria for borderline personality disorder as well. Such
individuals are also more frequently depressed. Conversely, research shows
dissociative symptoms in many patients with borderline personality disorder,
especially those who report his-tories of physical and sexual abuse. Indeed,
the impulsiveness, splitting, hostility and fear of abandonment, frequently
seen in certain personality states, are similar to the presentation of many
patients with borderline personality disorder. Many such patients also have
symptoms that meet criteria for PTSD, with intrusive flashbacks, recurrent
dreams of physical and sexual abuse, avoid-ance of and loss of pleasure in
usually pleasurable activities, and symptoms of hyperarousal, especially when
exposed to remind-ers of childhood trauma.
Thus, comorbidity is a complex issue. In addition, these patients are
not infrequently misdiagnosed as having schizophre-nia (Kluft, 1987). This
diagnostic confusion is understandable in that they have an apparent delusion
that their bodies are occu-pied by more than one person. In addition, they
frequently have auditory hallucinations when one personality state speaks to or
comments on the activities of another. When misdiagnosed as schizophrenic,
patients with DID are frequently given neurolep-tics, which results in a poor
therapeutic response and a flattening of affect, which tends to confirm the
misdiagnosis (since flat af-fect is characteristic of schizophrenia).
Individuals with DID commonly report somatic or conver-sion symptoms and
other psychosomatic symptoms, such as mi-graine headaches. Studies have shown
that approximately a third of these patients have complex partial seizures
(Schenk and Bear, 1981), although later studies did not show seizure rates that
high. Furthermore, the studies did not show substantial elevations in scores on
Dissociative Experiences Scale in patients with com-plex partial seizures as
compared with those of other neurologi-cal patients (Loewenstein and Putnam,
1988). However, there is sufficient comorbidity that patients recently
diagnosed with DID should be evaluated for the possibility of a seizure
disorder
The diagnosis can be facilitated by psychological testing. Scales of
trait dissociation have been developed (Bernstein and Putnam, 1986; Ross, 1989;
Carlson et al., 1993), and patients
with DID score extremely high on these scales, in contrast to normal
popu-lations and other groups of patients. Those with DID score far higher than
normal individuals on standard measures of hypno-tizability, whereas
schizophrenic patients tend to have lower than normal scores or the absence of
high hypnotizability. Thus, there is comparatively little overlap in the
hypnotizability scores of pa-tients with schizophrenia and those with DID. Form
level on the Rorschach test is usually within the normal range, but there are
frequent emotionally dramatic responses, often involving mutila-tion
(especially with the color cards) of a type that is often seen in histrionic
personality disorder as well. Form level is an assess-ment of the match between
the percept (what the subject reports seeing) and the inkblot structure. Good
form level involves rela-tively little distortion of the image to match percept
to inkblot. Good form level is useful in distinguishing patients with DID from
those with schizophrenia, who have poor form level.
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