Dissociative identity disorder

Dissociative identity disorder is a diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Revised, as the existence in an individual of two or more distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. At least two of these personalities are considered to routinely take control of the individual's behavior, and there is also some associated memory loss, which is beyond normal forgetfulness. This memory loss is often referred to as "losing time". These symptoms must occur independently of substance abuse, or a general medical condition. See DSM-IV-TR Dissociative identity Disorder Diagnostic Criteria for a more complete overview.

Dissociative identity disorder was initially referred to as Multiple personality disorder, and, as referenced above, remains defined as such in the International Statistical Classification of Diseases and Related Health Problems.

It is important to note that no matter what the categorization, dissociation, Dissociative identity disorder, and/or Multiple personality disorder are in no way related to schizophrenia. This is a prevalent belief, but a misconception nonetheless.

The causes and treatment of Dissociative Identity Disorder (and its DSM predecessor, Multiple personality disorder) remain controversial, as discussed below.

Dissociation
Dissociation is a complex mental process which allows children and adults to survive very painful and traumatic situations. It is characterized by a dis-integration of the ego. Ego integration, or more properly ego integrity. It can be defined as a person's ability to successfully incorporate external events or social experiences into their perception, and to then present themselves consistently across those events or social situations. A person unable to do this successfully can experience a collapse of ego integrity, as well as potential emotional dysregulation. This state of emotional dysregulation is, in some cases, so intense that it can precipitate ego dis-integration, or what, in extreme cases, has come to be referred to diagnostically as dissociation.

Dissociation describes a collapse in ego integrity so profound that the personality is considered to literally break apart. For this reason, dissocation is often referred to as "splitting" or "altering". Less profound presentations of this condition are often referred to clinically as disorganization or decompensation. The difference between a psychotic break and a dissociation, or dissociative break, is that, while someone who is experiencing a dissociation is technically pulling away from a situation that s/he cannot manage, some part of the person remains connected to reality. While the psychotic "breaks" from reality, the dissociative disconnects, but not all the way.

Because the person suffering a dissociation does not completely disengage from his/her reality, s/he may appear to have multiple "personalities". In other words, different "people" (read: personalities) to deal with different situations, but generally speaking, no one person (read: personality) who will retreat altogether.

The DSM re-dress
There is considerable controversy (see Multiple personality controversy) over the validity of this diagnostic profile, as, unlike the more empirically verifiable mood and personality disorders, dissociation is primarily subjective for both the patient, and the treatment provider. While other disorders do, indeed, require a certain amount of subjective interpretation, those disorders more readily present with generally accepted, objective symptomology. The controversial nature of the dissociation hypothesis evidences itself quite clearly by the manner in which the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has addressed, and re-dressed, the categorization over the years.

The 2nd Edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to this diagnostic profile as Multiple Personality Disorder. The 3rd Edition of the DSM Manual grouped Multiple Personality Disorder in with the other 4 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.

Research indications
One of the primary reasons for the on-going re-categorization of this condition is that, until 1944, there were only 79 documented cases of what was then referred to as multiple personality. Although the condition does have a long history stretching back in the literature some 300 years, it remains a rare disorder, affecting less than 1% of the population. Conversely, dissociation is now 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-symptomology, it has become more frequent as an ancillary diagnosis, rather than a primary diagnosis. A full blown DID diagnosis, that intends an individual is evidencing quantifiable multiple personalities and presents itself independently of a primary personality disorder, remains rare.

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:


 * 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, should it be defined in psychoanalytic terms?
 * 4) Whether it can be cured.
 * 5) Whether it should be cured.
 * 6) Who should primarily define the experience -- therapists, or those who believe that they have multiple personalities?
 * 7) Whether it is invariably a disorder or simply a way of being.

The skeptical claim that people who present with the appearance of MPD/DID may have learned to exhibit the symptoms in return for social reinforcement, either from therapists, from others with DID, from society at large, or from any combination thereof.

Another view is that multiplicity is not always a disorder (see: "healthy multiplicity") and that it can be normal to experience oneself as multiple, so that it is possible to be multiple without having MPD or DID. From the stand point of Carl Jung's Analytic Psychology, this could be characterized as a hyper-awareness of one's personas.

Potential causes
Dissociative identity disorder is attributed 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--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 disorder. 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.

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.

Symptoms
Patients often have a remarkable array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic and mood psychoses, and seizure disorders. Symptoms can include:
 * Depression
 * 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 amnesia
 * sexual dysfunction
 * eating disorders
 * posttraumatic stress
 * Suicidal preoccupations and attempts are common
 * episodes of self-mutilation
 * psychoactive substance abuse

Other symptoms 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.

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 ages 6 and 11. Amnesia for earlier events is normal and widespread.

Diagnosis
If symptoms seem to be present, the patient should first be evaluated by performing a complete medical history and physical examination. The various diagnostic tests, such as X-rays and blood tests are 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 amnesia.

If no physical illness is found, the patient might be referred to a psychiatrist or psychologist. Psychiatrists and psychologists use specially designed interview and personality assessment tools to evaluate a person for a dissociative disorder.

DSM-IV-TR diagnostic criteria
The current diagnostic criteria for Dissociative identity disorder published in the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders can be found here:

DSM-IV-TR Dissociative identity Disorder Diagnostic Criteria

Prognosis
Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and posttraumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of other serious psychiatric disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. They improve more slowly, and treatment may be either less successful or longer and more crisis-ridden. Patients in the third group not only have severe coexisting psychopathology but may also remain enmeshed with their alleged abusers. Treatment is often long and chaotic and aims to help reduce and relieve symptoms more than to achieve integration. Sometimes therapy helps a patient with a poorer prognosis make rapid strides toward recovery.

Treatment
Perhaps 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 treament modalities that do not depend upon integrating the seperate 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.
 * Creative therapies 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, allowing people to explore thoughts, feelings and memories they might have hidden from their conscious minds*

People with DID generally respond well to treatment; however, treatment can be a long and painstaking process. To improve a person's outlook, it is important to treat any other problems or complications, such as depression, anxiety or substance abuse.

References and external links

 * Webmd.com
 * Merck.com The Merck Manual.
 * DSM-IV-TR Dissociative identity Disorder Diagnostic Criteria Diagnostic and Statistical Manual of Mental Disorders.
 * Piper A, Merskey H. The persistence of folly: A critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept. Can J Psychiatry 2004;49:592–600
 * Piper A, Merskey H. The persistence of folly: A critical examination of dissociative identity disorder. Part II. The defence and decline of multiple personality or dissociative identity disorder. Can J Psychiatry 2004;49:678–83.
 * Putnam, Frank W., The Diagnosis and Treatment of Multiple Personality Disorder, Guilford Press, New York, 1989
 * Multiple Personality Disorder: Fact or Fiction? Alexandria K.Cherry Rochester Institute of Technology
 * Guidelines for Treating Dissociative Identity Disorder in Adults (2005) James A. Chu, MD
 * Multiple Personality Disorder in the Courts Dr. David V. James MA, MRCPsych (UK)
 * Dissociative Identity Disorder(formerly Multiple Personality Disorder) Nami.org
 * Mental Health: Dissociative Identity Disorder (Multiple Personality Disorder) WebMd.com
 * Creating Hysteria by Joan Acocella, 1999.
 * Multiple Identities and False Memories by Nicholas Spanos, 1996, ISBN 1-55798-340-2
 * Essay from the Skeptic's Dictionary
 * International Society for the Study of Dissociation

Voices of multiples

 * Amorpha: Collective Phenomenon Non-disordered multiplicity from an art and political viewpoint.
 * Astraea Articles and links exploring the idea of healthy, non-disordered multiplicity.
 * In Essence We Declare Example of a healthy self-identified multiple group's co-signed agreement to maintain responsibility and functionality.
 * The Layman's Guide to Multiplicity (non-disordered multiplicity resource, written and edited by multiples)
 * Mental Health Matters: Dissociative Identity Disorder
 * Pavilion Awareness taskforce for functional multiplicity. Educate the public, media campaigns correcting misportrayals of multiples as helpless victims, crazed killers, etc.
 * Pilgrim's Journey A blog written by a young woman with Dissociative Identity Disorder.
 * Psych Forums: DID Forum
 * Sean Reynolds' allegedly true story of a relationship with a girl who suffered from Dissociative Identity Disorder
 * Sidran Foundation A nonprofit organization disseminating information concerning the treatment of trauma.
 * Elisabeth Pruitt Brown A husband's memory page to his deceased multiple wife.

Dissoziative Identitätsstörung & Dissociatieve identiteitsstoornis & Dissosiatiivinen identiteettihäiriö Dissociativ identitetsstörning