Dissociative Identity Disorder 1

RUNNING HEAD: CASE STUDY ON DISSOCIATIVE IDENTIY DISORDER

James Cook University Singapore

Case Study on Dissociative Identity Disorder

Pear Chi Guan (12332056)

Fok Kean Jeong (12379048)
Mildred Tan Xin Yu (12392289)

Dissociative Identity Disorder 2

Introduction
Dissociation is defined as A disruption in the usually integrated functions of consciousness,
memory, identity, or perception (APA, 1994).Dissociative identity disorder is a disorder
characterized by identity fragmentation characterized by the presence of two or more distinct
identities or personality states that recurrently take control of the individuals behaviour. This
is also accompanied by an inability to recall important personal information that cannot be
explained by ordinary forgetfulness, it is also commonly accompanied by other symptoms
such as headaches, hallucinations, suicide attempts and self-abusive behaviour (Kring,Ann
M., Gerald C. Davison, John M. Neale, Sheri L. Johnson, 2005). Research has also shown
that it is extremely rare to see a case of dissociative identity disorder without any additional
psychiatric disorders like depression, substance use disorders and borderline personality
disorder (Putnam F.W, Guroff J.J, Silberman E.K, 1986; Anderson G, Yasenik L, Ross C.A,
1993). However, for this paper we would only be focusing on Dissociative identity disorder.
First of all, one of the most important students of the theory of dissociation was Pierre
Janet (1920), who suggested that in response to trauma, dissociative disordered patients
develop a set of characteristic psychological processes that serve to keep some experiences
out of conscious integration with the bulk of mental life (Janet P, 1920). Following that, two
major theories of DID the posttraumatic model and the sociocognitive model. The
posttraumatic model emphasises that DID begins in childhood as a result of severe physical
or sexual abuse (Kring et al., 2005). While the sociocognitive model emphasises that DID to
be the result of learning to enact social roles, which can be suggested through therapy, media
or other cultural influences (Kring et al., 2005). Other suggestions regarding DID are for
instance, Armstrongs theory that dissociation is a factor that promotes resiliency in the midst
of trauma by helping to preserve essential human intellectual and emotional capacities such
as hour, hope and joy (Armstrong JG, 1994). A more clinical perspective on how dissociation

Dissociative Identity Disorder 3

can be explained can be found through the neurological model, which suggests that some
underlying neurological process, such as hemispheric disconnection or epilepsy plays a role
in promoting dissociative symptoms (Maldonado JR, 2007).

Diagnosis of DID
As discussed earlier on, individuals with DID usually experience various comorbid
conditions. Therefore the diagnosis of DID should not be simply based on the background
information or symptoms provided by the patients, it should involve a complex process which
includes a battery of tests and also requires the assessors to have knowledge of the
assessment and also the disorder itself. Like many psychological disorders, it requires the
patient to reveal what is often a private, hidden world to a stranger. Thus a collaborative
relationship will definitely help in the results.
To begin the diagnosis, two test of dissociation namely the Dissociative Experiences
Scale (DES) and the Structured Clinical Interview for DSM-IV Dissociative DisordersRevised (SCID-D-R) which has extensive reviews could be used (Bernstein EM, Putnam FW,
1986; Steinberg M., 1994). The DES is a 28-item self-report scale that requires the
respondent to indicate the frequency of various dissociative experiences, such as
derealization, depersonalization, and psychogenic amnesia on 100-mm visual analogue scales
(VAS). A sample item is Some people have the experience of looking in a mirror and not
recognizing themselves. Mark the line to show what percentage of the time this happens to
you. The anchors of the 100-mm VAS are 0 (never) and 100 (always). The DES also exhibits
high internal consistency and test-retest correlations ranging from .74 to .84 (Bernstein EM,
Putnam FW, 1986; Timo Giesbrecht, Harald Merckelbach, 2006).

Dissociative Identity Disorder 4

The SCID-D-R is a semi structured interview developed by Steinberg, Rounsaville,

and Cicchetti (1990) with 200 questions to assess the presence and severity of amnesia,
depersonalization, derealisation, identity confusion, and identity alteration symptoms. Each
symptom is then rated on a 4-point scale and ratings of severe are generally awarded if a
symptom is present for a prolonged period, occurs frequently, produces dysphoria or
produces impairment in social or occupational functioning. General, open-ended screening
questions are followed by more detailed questions. SCID-D-R also exhibits a high inter-rater
reliability of .90 for the diagnosis of DID (Steinberg, M., Rounsaville, B., & Cicchetti, D.,
1990).
Projective tests can also be particularly useful in assessing DID because the ambiguity
of the tests requires an individual to project their own ways of organizing reality onto the
tests (Bethany L. Brand, Judith G. Armstrong, Richard J. Loewenstein, 2006). One such test
is the Thematic Apperception Test (TAT) which consists of 20 black-and-white drawings that
depict people and scenes (Armstrong JG, 1996). Subjects would be told to tell stories to
describe the characters thoughts and feelings. This provides a description of how the subject
expects people to interact both internally in their altered world and externally in the social
world. One example is that adolescents who are traumatized have been found to tell TAT
stories that are characterized by negative affect, and have characters that are malevolent and
self-centered, with themes of violence (Armstrong JG, Kaser-Boyd N., 2004).
Another projective test is the Rorschach test which is useful because it requires the
subjects to delve into their internal store of associations, which is the very thing dissociation,
has been helping them to avoid. It also provides a broad view of a persons cognition and
problem solving skills. Patients with dissociative disorders have been found to be flooded
with emotions and bothersome percept while completing the Rorschach (Bethany L. Brand,
Judith G. Armstrong, Richard J. Loewenstein, 2006).

Dissociative Identity Disorder 5

In spite of battery of tests, diagnosing DID should also be based on the DSM-IV
diagnostic criteria (APA, 1994), which are A. The presence of two or more distinct identities
or personality states (each with its own relatively enduring pattern of perceiving, relating to,
and thinking about the environment). B. At least two of these identities or personality states
recurrently take control of the persons behaviour. C. Inability to recall important personal
information that is too extensive to be explained by ordinary forgetfulness. D. The
disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or
chaotic behaviour during alcohol intoxication) or a general medical condition (e.g., complex
partial seizures).

Therapy
There are numerous examples of treatment for DID, most psychodynamic treatments
basically involve the same processes. The process of psychodynamic treatment we are
emphasising on for this case would involve six-stages: (a) establishing the diagnosis, (b)
developing awareness of multiplicity, (c) developing awareness of past history and the
purpose of alters, (d) working through the dissociative defences, (e)integration and fusion
and (f)termination. Each of these stages involves a complex process which integrates with h
and would take around an average of two-years, with 2-3 sessions per week on a basis of 2hrs
per session.
The first stage of the treatment would require establishing a therapeutic relationship
and a high degree of trust as it is essential in the context of ongoing psychotherapy
(Horevitz,R., 1983). In addition, it is also important to establish trust with both the host and
his/her different personalities/identities as well as not to ignore or favour one identity over
another since cooperation is needed from all personalities (Putam, F. W., 1989).

Dissociative Identity Disorder 6

Once a working relationship has been establish in stage one, the second stage of the
therapy can be undertaken: developing awareness of multiplicity. At this stage, the patient
must come to terms and acknowledge his/her diagnosis (MacGregor, 1996). For this reason a
healthy working relationship with the patient have to be established at stage one. For instance
according to the posttraumatic model, disassociation is used as a defence mechanism to avoid
the trauma experienced (Kring,Ann M., Gerald C. Davison, John M. Neale, Sheri L. Johnson,
2005). Therefore being able to aware and acknowledge the existence of the multiplicity of
alters and the dissociative coping style would facilitate the following stages of therapy.
The purpose of the third stage of therapy is to help the patient become aware of
his/her early traumatic experiences and how each of the alters developed as a coping device
towards the trauma experienced (MacGregor, 1996). The goal of this phase is to lessen and
then eliminate the need for dissociative barriers. Mapping can be incorporated in this stage,
which is a technique that allows patients to develop a physical map of their personality
system. From this map, therapist can gather valuable information regarding the nature of the
different personalities to help generate a deeper understanding of these personalities and
ensure that all alters are being addressed (Ross, C. A., & Gahan, P., 1988). Additionally, this
would also help facilitate the realization for the DID patient. An age regression technique
from hypnosis can also be integrated at this stage to help facilitate the mapping, this involves
using hypnosis to bring the patient back to a time when these different personalities were
manifested (MacGregor, 1996).With reference to the social-cognition model, these
personalities evolved from social-cultural factors that varied between social contexts. Hence
being able to understand these personalities would also create a deeper understanding of the
patient and his/her social barriers and dissociative defences (Scott O.Lilienfeld, Irving Kirsch,
Theodore R. Sarbin, 1999). Consequently this information would help the patient overcome
them at the later stages of the therapy.

Dissociative Identity Disorder 7

The fourth stage of the therapy involves working through dissociative defences by
piecing together events, memories, and feelings so that full memories can be constructed.
One of the goals of this stage of therapy includes increase in internal communication, which
is facilitated by having the alters talk to each other (MacGregor, 1996). Methods of hypnosis
can be in- cooperated at this stage, specifically memory retrieval which allows the patient to
relieve traumatic memories at a controlled level and in addition, focus on working through
the painful affect, inappropriate self-blame and other reactions to these memories. Screen
techniques can also be introduced, where the patient visualizes these memories and divides
them onto two sides of an imaginary screen (MacGregor, 1996). For example, a woman
manages to remember a particularly painful episode in hypnosis. When she was 12 years
old, her stepdad forced her to have oral sex with him, she recalled what he was forcing her to
do and remembered that she gagged and vomited all over him, which spoiled his fun. One
side of the imaginary screen would picture what an abuse did to the patient, and the others
side would picture how the patient tried to protect himself or herself from the abuse.
Subsequently, the patient is able to reduce fragmentation and increase integration of these
memories in consciousness with a broader perspective of these traumas and therefore
reducing the need for dissociation as a means of keeping such memories out of consciousness
(Lindemann E, 1994).
Stage 5, comprises of fusion and integration. Fusion is the process of removing the
dissociative barriers that segregate specific alters. Integration is the complete and pervasive
restructuring of the personality which involves the combination of the separate alters and
elements of alters into a unified personality (Putam, F. W., 1989). The therapist must
continuously work with the patient to consolidate the new integrated self and the patient must
also actively develop and use non-dissociative defence mechanisms within the new integrated
self

Dissociative Identity Disorder 8

At the final stage of therapy, the patient should have managed to integrate all of the
personalities and develop new nondissociative defence mechanisms. Nevertheless,
termination should only occur when the therapist feels that the patient is ready to deal with
the anxiety and stress of the social environment in a nondissociative manner.

The rule of thirds (Kluft RP, 1988) is a helpful guideline for psychotherapy as it
emphasises that therapist should spend the first one third of the therapy session assessing the
patients current mental state, life problems and also defining a problem area that might
benefit from retrieval into conscious memory and working through. The second third of the
therapy, the therapist can then access and work thought the patients memory, and finally
ending with helping the patient assimilate the information, regulate and modulate emotional
responses as well as discuss any responses to the therapist and plans for the immediate future.
Disassociation is usually used as a defence for DID patients, therefore it is important
for the patient to acknowledge that they experience themselves as fragmented, yet the reality
is that this fragmentation is a failure of integrating disparate memories and aspects of the self.
Consequently, therapies for DID should have a goal to facilitate integration of these elements.
A series of rules of engagement (JR, Maldonado, 2000) should also be used during the
treatment as these rules would help facilitate free access to old records and permission to
discuss all past and current information. Secrets are also a frequent problem for therapies
with DID patients as patients often like to confine plans or stories from the therapist, so as to
keep it from the other parts or the manifested parts of the self. Examples of these can be
traumatic memories or plans for self-destructive activities. Hence with this set of rules there
should be not secrets kept between therapist and client, and also confidentiality should not
apply between identities as this would hinder the process of integration.

Dissociative Identity Disorder 9

Hypnosis can be helpful in both diagnosis and treatment of DID. Firstly, hypnotic
induction may elicit dissociative phenomena or activate alters/identities. The capacity to elicit
such symptoms on command provides the first hint of the ability to control these symptoms.
Using hypnosis, the therapist can also apply age regression to help the patient reorient to a
time when these different personality states was manifested. Alternatively, it would be
possible to simply call up these different identities and speak to these identities.
Also, memory loss in DID is complex and chronic, therefore its retrieval should also
be integrated into the psychotherapy. The strategy of memory retrieval focuses on working
through traumatic memories in addition to controlling the dissociation. This ability to control
the access the memories would greatly facilitate the therapy as the therapist can use hypnosis
to help the patient interact with different identities. In addition to that, the patient can work
through the painful affect, inappropriate self-blame and other reactions to these memories. A
model of grief work can be helpful as it enables the patient to acknowledge and bear the
import of such memories (Lindemann E, 1994)
Being able to visualize these memories would also be important as patients can also
divide the memories onto two sides of an imaginary screen which places them in a broader
perspective of these traumatic memories. Thus allow these traumatic memories to be more
bearable. One example of this technique is a woman manages to remember a particularly
painful episode in hypnosis. When she was 12 years old, her stepdad forced her to have oral
sex with him, she recalled what he was forcing her to do and remembered that she gagged
and vomited all over him, which spoiled his fun. One side of the imaginary screen would
picture what an abuse did to the patient, and the others side would picture how the patient
tried to protect himself or herself from the abuse. Besides that, this technique also reduces
fragmentation and integration by enabling patients to bear the memories in consciousness and

Dissociative Identity Disorder 10

therefore reducing the need for dissociation as a means of keeping such memories out of
consciousness.
Before a hypnotherapy can be carried out successfully, it requires the clients
willingness to cooperate (Braun, 2008). However, many people have misconceptions of
hypnosis, such as being made to do things that are morally opposing. Thu, the therapist will
have to clear the clients misconceptions and reassure him that he will not lose control of
himself during hypnosis.
During therapy with DID patients, transference would sometimes be present, as
patients expect therapist to exploit them, just like how they presume that their caregivers who
acted in an exploitative and sadistic fashion. Therefore it is important to make these issues
frequent topics of discussion.
Transference frequently involves unconscious repetition of the past in present.

The

relational model of psychoanalysis regards transference as an interactive process between the

client and the therapist (Corey, 2009). Through the interaction, the client may gradually be
conscious of their feelings as they start to exhibit a range of reactions and feelings to the
therapist. The client can then recognize and resolve events that have traumatized them from
past relationships. With the progression of each therapy, the feelings and conflicts which the
client experienced during childhood may begin to surface from the depths of
unconsciousness, resulting in him/her to regress emotionally. From there, the issues which the
client faced will slowly surface and this can be worked on individually.
Another method to deal with transference is applying the Empty Chair Technique
from Gestalt therapy as it allows the client to fully express his repressed feelings and
emotions by bringing the unresolved past into the present. However, the Empty Chair
Technique should only be applied towards the end of the therapy as the therapist should gain

Dissociative Identity Disorder 11

the clients trust through congruency and the rapport between the therapist and client must be
built before this therapy can be carried out successfully(Corey, 2009).
At the start of this phase of therapy, the client will be seated next to the therapist, with
an empty chair being placed in the opposite direction of them. In this instance, the clients
unresolved past will be his mother. The client will be asked to imagine greeting his mother
and inviting her into the therapy room and seated down on the empty chair. The client will
then be encouraged to speak to his mother regarding how he felt about his mother, the past
events and even things that he wished he could tell his mother but never had a chance to do
so. After several sessions using the Empty Chair Technique, the therapist should also
encourage the client to perform positive actions such as hugging his mother. Subsequently,
the client should also give his mother a voice. For instance, the client may be asked how he
thinks his mum might respond to him, after expressing how he felt.
Ultimately, this therapys goal should be the integration of the disparate states. As
early in the therapy, dissociation is the primary defence for the patient. Hence, being able to
experience and work though fears with the help of a degree of integration and control of his
or her dissociative processes would set aside this dissociative defence.
**Other therapies.
Pharmacology drugs are widely used to help manage DID symptoms such as
depression, anxiety, impulsivity, and substance abuse. However, these drugs do not relieve
dissociation. Proper treatment is still needed to achieve integration which centers on
psychotherapy. (Schatzberg, 2000). Although there are no medications that specifically treat
DID, antidepressants, anti-anxiety medications or tranquilizers may be prescribed by doctors
to help control the mental health symptoms associated with DID. For patients who are unable

Dissociative Identity Disorder 12

or unwilling to strive for integration, psychotherapy aims to facilitate cooperation and

collaboration among the identities and to reduce these symptoms.
Etiology
Subject suffered from sexual abuse during his childhood. These mistreatments lead to
overwhelming stress. As the child was mistreated by a trusted caregiver, splitting off the
awareness and memory of the traumatic event helped him survive in the relationship between
his foster parents. These memories and feelings go into subconscious state of the mind and
were later experienced in the form of a separate identity.
Dissociation becomes a coping mechanism when the individual is faced with a similar
stressful event, insufficient nurturing and compassion in response to overwhelmingly hurtful
experiences during childhood (Gleaves, D. 1996). Most people found suffering from DID are
usually victims of emotional, sexual or physical abuse. Some others suffering from this
disorder may not have experience early loss such as death of someone close to them or
experienced some stressful events (Kluft, R.P.1988).
These individuals may go through different cognitive phases such as emotional,
perception and memories of their life experience kept separated to help them escape from the
experience by zoning out or retreat into their own world. This will lead to a different state of
mind with the presence of two or more personalities. They will experience inability of at least
one of the altered state to recall important personal information (Gleaves, D. 1996).

Gleaves, D. (July 1996). "The sociocognitive model of dissociative identity disorder:

a reexamination of the evidence". Psychological Bulletin 120 (1): 4259.

Dissociative Identity Disorder 13

Kluft RP. (1988). The dissociative disorder. Washinhton, DC: American Psychiatric Press.

Schatzberg, A.F. (2000). "New indications for antidepressants". Journal of Clinical

Psychiatry 61 (11): 917.

(Corey, 2009) (Braun, 2008 )

Anderson G, Yasenik L, Ross C.A. (1993). Dissociative experiences and disorders
among women who identify themselves as sexual abuse survivors. Child Abuse ,
677-686.
Armstrong JG. (1994). Reflections on multiple personality disorder as a
develipmentally complex adaptation. Psychoanal Study Child , 49: 349-64.
Armstrong JG. (1996). Treating dissociative identity disorder. Psychological
assessment .
Armstrong JG, Kaser-Boyd N. (2004). Projective assessment of psychological
trauma. Comprehensive handbook of psychological assessment , 500-512.
Association, A. P. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC.

Dissociative Identity Disorder 14

Bernstein EM, Putnam FW. (1986). Development, reliability, and validity of a
dissociation scale. J Nerv Ment Dis , 174: 727-34.
Bethany L. Brand, Judith G. Armstrong, Richard J. Loewenstein. (2006).
Psychological Assessment of Patients with Dissociative Identity Disorder.
Psychiatrc clinics of North America , 145-168.
Braun, B. G. (2008 , November 29). Uses of Hypnosis with Dissociative Identity
Disorder . Retrieved March 13, 2010, from Healthy place - America's Mental
Health Channel : http://www.healthyplace.com/abuse/wermany/uses-of-hypnosiswith-dissociative-identity-disorder/menu-id-846/page-4/
Corey, G. (2009). Theory and Practice of Counseling and Psychotherapy.
Thomsom Brooks/Cole.
Horevitz,R. (1983). Hypnosis for multiple personality disorder: A critical review.
Journal of Psychiatry , 138-145.
Janet P. (1920). The Major Symptoms of Hysteria: Fifteen Lectures Given in the
Medical School of Harvard University. New York: Macmillan.
JR, Maldonado. (2000). Diagnosis and treatment of dissociative disorders, in
Manual for the course. Chicago, IL: American Psychiatric Association.
Kluft RP. (1988). The dissociative disorder. Washinhton, DC: American Psychiatric
Press.
Kring,Ann M., Gerald C. Davison, John M. Neale, Sheri L. Johnson. (2005).
Abnormal Psychology. Wiley.
Lilien, S. O., Kirsch. I., Sarbin, T. R., Lynn, S. J.,Chaves, J. F., Ganaway, G. K.
(1999). Dissociative Identity Disorder and the Sociocognitive Model: Recalling the
Lessons of the Past. Psychological Bulletin , 5, 507-523.
Lindemann E. (1994). Symptomatology and management of acute grief. Am J
Psychiatry , 155-160.
MacGregor, M. W. (1996). Multiple Personality Disorder: Etiology, Treatment, and
Treatment Techniques From a Psychodynamic Perspective. Psychoanalytic
psychology , 39-402.
Maldonado JR. (2007). Conversion disorder, in Gabbard's Treatments of
Psychiatric Disorders. Washington, DC: anerican Psychiatric Publishing.
Putam, F. W. (1989). Diagnosis and treatment of a case of multiple personality
disorder: First findings. New York: Guilford.
Putnam F.W, Guroff J.J, Silberman E.K. (1986). The clinical phenomenology of
multiple personality disorder: review of 100 recent cases. J Clin Psychiatry , 285293.

Dissociative Identity Disorder 15

Ross, C. A., & Gahan, P. (1988). Techniques in the treatment of multiple
personality disorder. American Hournal of Psychotherapy , 40-52.
Scott O.Lilienfeld, Irving Kirsch, Theodore R. Sarbin, Steven Jay Lynn, John F.
Chaves, George K. Ganaway & Russell A. Powell. (1999). Dissociative Identity
Disorder and the Sociocognitive Model: Recalling the lessons of the Past.
American Psychological Association , 507-523.
Steinberg M. (1994). Structured Clinical Interview for DSM-IV Dissociative
Disorders-Reviesed (SCID-D-R). Washington. DC: American Psychiatric Press.
Steinberg, M., Rounsaville, B., & Cicchetti, D. (1990). The structured clinical
interview for DSM-III-R dissociative disorders: preliminary report on a new
diagnostic instrument. American Journal of Psychiatry , 76-81.
Timo Giesbrecht, Harald Merckelbach. (2006). Dreaming to reduce fantasy?Fantasy proneness, dissociation, and subjective sleep experiences. Personality
and Individual Differences , 697-706.