Professional Documents
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Dissociative Disorders
Dissociative Disorders
Dissociative Disorders
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Dissociative Disorder
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Dissociative disorders
Definition
Description
2
without noticing or remembering. Dissociation is related to hypnosis in that
hypnotic trance also involves a temporarily altered state of consciousness. Most
patients with dissociative disorders are highly hypnotizable.
The dissociative disorders vary in their severity and the suddenness of onset. It is
difficult to give statistics for their frequency in the United States because they are a
relatively new category and are often misdiagnosed. Criteria for diagnosis require
significant impairment in social or vocational functioning.
3
that symptoms can result, to the extent of interfering with a person's general
functioning, when one or more of these functions is disrupted.
As society has become increasingly aware of the prevalence of child abuse and its
serious consequences, there has been an explosion of information on
posttraumatic and dissociative disorders resulting from abuse in childhood. Since
most clinicians learned little about childhood trauma and its aftereffects in their
training, many are struggling to build their knowledge base and clinical skills to
effectively treat survivors and their families.
4
rape. Dissociative Fugue is indicated by not only loss of memory, but also travel to
a new location and the assumption of a new identity. Posttraumatic Stress
Disorder (PTSD), although not officially a dissociative disorder (it is classified as
an anxiety disorder), can be thought of as part of the dissociative spectrum. In
PTSD, recall/re-experiencing of the trauma (flashbacks) alternates with numbing
(detachment or dissociation), and avoidance. Atypical dissociative disorders are
classified as Dissociative Disorders Not Otherwise Specified (DDNOS). If the
disturbance occurs primarily in identity with parts of the self assuming separate
identities, the resulting disorder is Dissociative Identity Disorder (DID), formerly
called Multiple Personality Disorder.
The dissociative spectrum (Braun, 1988) extends from normal dissociation to poly-
fragmented DID. All of the disorders are trauma-based, and symptoms result from
the habitual dissociation of traumatic memories. For example, a rape victim with
Dissociative Amnesia may have no conscious memory of the attack, yet experience
depression, numbness, and distress resulting from environmental stimuli such as
colors, odors, sounds, and images that recall the traumatic experience. The
dissociated memory is alive and active--not forgotten, merely submerged (Tasman
& Goldfinger, 1991). Major studies have confirmed the traumatic origin of DID
(Putnam, 1989, and Ross, 1989), which arises before the age of 12 (and often before
age 5) as a result of severe physical, sexual, and/or emotional abuse. Poly-
fragmented DID (involving over 100 personality states) may be the result of
sadistic abuse by multiple perpetrators over an extended period of time.
5
Although DID is a common disorder (perhaps as common as one in 100) (Ross,
1989), the combination of PTSD-DDNOS is the most frequent diagnosis in
survivors of childhood abuse. These survivors experience the flashbacks and
intrusion of trauma memories, sometimes not until years after the childhood
abuse, with dissociative experiences of distancing, "trancing out", feeling unreal,
the ability to ignore pain, and feeling as if they were looking at the world through a
fog.
Symptoms
The symptom profile of adults who were abuse as children includes posttraumatic
and dissociative disorders combined with depression, anxiety syndromes, and
addictions. These symptoms include (1) recurrent
depression; (2) anxiety, panic, and phobias; (3)
anger and rage; (4) low self-esteem, and feeling
damaged and/or worthless; (5) shame; (6) somatic
pain syndromes (7) self-destructive thoughts
and/or behavior; (8) substance abuse; (9) eating
disorders: bulimia, anorexia, and compulsive
overeating; (10) relationship and intimacy
difficulties; (11) sexual dysfunction, including
addictions and avoidance; (12) time loss, memory
gaps, and a sense of unreality; (13) flashbacks,
intrusive thoughts and images of trauma; (14) hypervigilance; (15) sleep
disturbances: nightmares, insomnia, and sleepwalking; and (16) alternative states
of consciousness or personalities.
Dissociative amnesia
6
Dissociative identity disorder
Dissociative fugue
Depersonalization disorder
A perception of the people and things around you as distorted and unreal
(derealization)
7
your head. Each of these identities may have name, personal history and
characteristics, including marked differences in manner, voice, gender and
even such physical qualities as the need for corrective eyewear. There often
is considerable variation in each alternate personality's familiarity with the
others. People with dissociative identity disorder typically also have
dissociative amnesia.
Causes
8
Dissociative disorders usually develop as a way to cope with trauma. The disorders
most often form in children subjected to chronic physical, sexual or emotional
abuse or, less frequently, a home environment that is otherwise frightening or
highly unpredictable.
Personal identity is still forming during childhood, so a child is more able than is
an adult to step outside herself or himself and observe trauma as though it's
happening to a different person. A child who learns to dissociate in order to
endure an extended period of his or her youth may use this coping mechanism in
response to stressful situations throughout life.
Risk factors
Complications
Self-mutilation
Suicide attempts
9
Sexual dysfunction, including sexual addiction or avoidance
Depression
Anxiety disorders
Diagnosis
10
age regression, out-of-body
experiences, and awareness of other
parts of self (Loewenstein, 1991).
11
A careful assessment should cover the basic issues of history (what happened to
you?), sense of self (how do you think/feel about yourself?), symptoms (e.g.,
depression, anxiety, hypervigilance, rage, flashbacks, intrusive memories, inner
voices, amnesias, numbing, nightmares, recurrent dreams), safety (of self, to and
from others), relationship difficulties, substance abuse, eating disorders, family
history (family of origin and current), social support system, and medical status.
After gathering important information, the therapist and client should jointly
develop a plan for stabilization (Turkus, 1991). Treatment modalities should be
carefully considered. These include individual psychotherapy, group therapy,
expressive therapies (art, poetry, movement, psychodrama, music), family therapy
(current family), psychoeducation, and pharmacotherapy. Hospital treatment may
be necessary in some cases for a comprehensive assessment and stabilization. The
Empowerment Model (Turkus, Cohen, & Courtois, 1991) for the treatment of
survivors of childhood abuse--which can be adapted to outpatient treatment--uses
ego-enhancing, progressive treatment to encourage the highest level of function
("how to keep your life together while doing the work"). The use of sequenced
treatment using the above modalities for safe expression and processing of painful
material within the structure of a therapeutic community of connectedness with
healthy boundaries is particularly effective. Group experiences are critical to all
survivors if they are to overcome the secrecy, shame, and isolation of survivorship.
Stabilization may include contracts to ensure physical and emotional safety and
discussion before any disclosure or confrontation related to the abuse, and to
prevent any precipitous stop in therapy. Physician consultants should be selected
for medical needs or psychopharmacologic treatment. Antidepressant and
antianxiety medications can be helpful adjunctive treatment for survivors, but they
should be viewed as adjunctive to the psychotherapy, not as an alternative to it.
12
Developing a cognitive framework is
also an essential part of stabilization.
This involves sorting out how an
abused child thinks and feels, undoing
damaging self-concepts, and learning
about what is "normal". Stabilization is
a time to learn how to ask for help and
build support networks. The
stabilization stage may take a year or
longer--as much time as is necessary
for the patient to move safely into the
next phase of treatment.
Revisiting and reworking the trauma is the next stage. This may involve
abreactions, which can release pain and allow dissociated trauma back into the
13
normal memory track. An abreaction might be described as the vivid re-
experiencing of a traumatic event accompanied by the release of related emotion
and the recovery of repressed or dissociated aspects of that event (Steele & Colrain,
1990). The retrieval of traumatic memories should be staged with planned
abreactions. Hypnosis, when facilitated by a trained professional, is extremely
useful in abreactive work to safely contain the abreaction and release the painful
emotions more quickly. Some survivors may only be able to do abreactive work on
an inpatient basis in a safe and supportive environment. In any setting, the work
must be paced and contained to prevent retraumatization and to give the client a
feeling of mastery. This means that the speed of the work must be carefully
monitored, and the release painful material must be thoughtfully managed and
controlled, so as not to be overwhelming. An abreaction of a person diagnosed
with DID may involve a number of different alters, who must all participate in the
work. The reworking of the trauma involves sharing the abuse story, undoing
unnecessary shame and guilt, doing some anger work, and grieving. Grief work
pertains to both the abuse and abandonment and the damage to one's life.
Throughout this mid-level work, there is integration of memories and, in DID,
alternate personalities; the substitution of adult methods of coping for
dissociation; and the learning of new life skills.
This leads into the final phase of the therapy work. There is continued processing
of traumatic memories and cognitive distortions, and further letting go of shame.
At the end of the grieving process, creative energy is released. The survivor can
reclaim self-worth and personal power and rebuild life after so much focus on
healing. There are often important life choices to be made about vocation and
relationships at this time, as well as solidifying gains from treatment.
This is challenging and satisfying work for both survivors and therapists. The
journey is painful, but the rewards are great. Successfully working through the
14
healing journey can significantly impact a survivor's life and philosophy. Coming
through this intense, self-reflective process might lead one to discover a desire to
contribute to society in a variety of vital ways.
Creative art therapy. This type of therapy uses the creative process to help
people who might have difficulty expressing their thoughts and feelings.
Creative arts can help you increase self-awareness, cope with symptoms and
traumatic experiences, and foster positive changes. Creative art therapy
includes art, dance and movement, drama, music, and poetry.
Cognitive therapy. This type of talk therapy helps you identify unhealthy,
negative beliefs and behaviors and replace them with healthy, positive ones.
It's based on the idea that your own thoughts — not other people or
situations — determine how you behave. Even if an unwanted situation has
not changed, you can change the way you think and behave in a positive
way.
15
Medication. Although there are no medications that specifically treat
dissociative disorders,
your doctor may
prescribe
antidepressants, anti-
anxiety medications or
tranquilizers to help
control the mental
health symptoms
associated with dissociative disorders
Alternative medicine
Hypnosis creates a state of deep relaxation and quiets the mind. When you're
hypnotized, you can concentrate intensely on a specific thought, memory, feeling
or sensation while blocking out distractions. Because you're more open than usual
to suggestions while under hypnosis, there is some controversy that therapists may
unintentionally "implant" false memories by suggestion. However, when
conducted under the care of a trained therapist, hypnosis is generally safe as a
complementary treatment method
Dissociative disorders are so-called because they are marked by a dissociation from
or interruption of a person's fundamental aspects of waking consciousness (such as
one's personal identity, one's personal history, etc.). Dissociative disorders come in
many forms, the most famous of which is dissociative identity disorder (formerly
16
known as multiple personality disorder). All of the dissociative disorders are
thought to stem from trauma experienced by the individual with this disorder. The
dissociative aspect is thought to be a coping mechanism -- the person literally
dissociates himself from a situation or experience too traumatic to integrate with
his conscious self. Symptoms of these disorders, or even one or more of the
disorders themselves, are also seen in a number of other mental illnesses,
including post-traumatic stress disorder, panic disorder, and obsessive compulsive
disorder.
17
18
Psychogenic Amnesia
Psychogenic amnesia, also known as functional or dissociative amnesia, is a
disorder characterized by abnormal memory functioning in the absence of
structural brain damage or a known neurobiological cause; severe cases are very
rare. It is defined by the presence of retrograde amnesia or the inability to retrieve
stored memories and events leading up to the onset of amnesia and an absence of
anterograde amnesia or the inability
to form new long term memories. In
most cases, patients lose their
autobiographical memory and
personal identity even though they
are able to learn new information and
perform everyday functions normally.
Other times, there may be a loss of
basic semantic knowledge and
procedural skills such as reading and
writing.
19
Memory and the brain
There are three types of memory – sensory, short-term, and long-term memory.
Sensory memory lasts up to hundreds of milliseconds and short-term memory lasts
from seconds to minutes while anything else longer than short-term memory is
considered to be a long-term memory.
The information obtained from the peripheral nervous system (PNS) is processed
in four stages - encoding, consolidating, storage, and retrieval. During encoding,
the limbic system is responsible for bottlenecking or filtering information obtained
from the PNS. According to the
type of information given, the
duration of consolidating stage
varies drastically. The majority
of consolidated information gets
stored in the cerebral cortical
networks where the limbic
system record episodic-
autobiographical events. These
stored episodic and semantic
memories can be obtained by triggering the uncinate fascicle that interconnects
the regions of the temporofrontal junction area.
20
prefrontal cortex in two stages - an initial suppression of the sensory aspects of the
memory, followed by a suppression of the emotional aspect. It has also been
proposed that glucocorticoids can impair memory retrieval; rats and human males
have been shown to be affected by this mechanism.
Traumas can interfere with several memory functions. Dr. Bessel van der Kolk
divided these functional disturbances into four sets: traumatic amnesia, global
memory impairment, dissociative processes and traumatic memories'
sensorimotor organization. Traumatic amnesia involves the loss of remembering
traumatic experiences. The younger the subject and the longer the traumatic event
is, the greater the chance of significant amnesia. Global memory impairment
makes it difficult for these subjects to construct an accurate account of their
present and past history. Dissociation refers to memories being stored as
fragments and not as unitary wholes. Not being able to integrate traumatic
memories seems to be the main element which leads to PTSD. In the sensorimotor
organization of traumatic memories, sensations are fragmented into different
sensory components.
21
as well as damage directly affecting cerebral areas critical for memory functioning
that cannot be detected in clinical history or neuroradiological exams.
Psychogenic amnesia is defined by the lack of structural damage to the brain, but
upon functional imaging, an abnormal brain activity can be seen. Tests using
functional magnetic resonance imaging suggest that patients with psychogenic
amnesia are unable to retrieve emotional memories normally during the amnesic
period, suggesting that changes in the limbic functions are related to the
symptoms of psychogenic amnesia. By performing a positron emission
tomography activation study on psychogenic amnesic patients with face
recognition, it was found that activation of the right anterior medial temporal
region including the amygdala was increased in the patient whereas bilateral
hippocampal regions increased only in the control subjects, demonstrating again
that limbic and limbic-cortical functions are related to the symptoms of
psychogenic amnesia.
Risk factors
22
corroboration of recovered memories of abuse is often present" and that the
recovery of the abuse memories generally is not associated with psychotherapy.
Theoretical explanations
Psychogenic amnesia is far from being completely understood and while several
explanations have been proposed, none of them have been verified as the
mechanism that fits all types of psychogenic amnesia. Different theories include:
Cognitive point-of-view states that this disorder utilizes the body’s personal
semantic belief system to repress unwanted memories from entering the
consciousness by altering neuropeptides and neurotransmitters released
during stressful events, affecting the formation and recall of memory.
23
the right hemisphere are more vulnerable to stress and trauma, affecting
the body's opioids, hormones, and neurotransmitters such as
norepinephrine, serotonin, and neuropeptide Y. Increased levels of
glucocorticoid and mineralocorticoid receptor density may affect the
anterior temporal, orbitofrontal cortex, hippocampal, and amygdalar
regions. These morphological changes may be caused by loss of regulation
of gene expressions in those receptors along with inhibition of neurotrophic
factors during chronic stress conditions.
Treatments
24
relax and attempt to recall memories. With the help of psychotherapy and
learning their autobiographies from family members, most patients recover
their memories completely.
Popular culture
Psychogenic amnesia is a common plot device in many films and books. Notable
examples include the character of Jason Bourne as depicted in the Bourne film
series, Jackie Chan in Who Am I?, Teri Bauer in 24, Goldie Hawn in Overboard,
Leroy Jethro Gibbs in NCIS.
25
Fugue State
A fugue state, formally Dissociative Fugue (previously called Psychogenic
Fugue) (DSM-IV Dissociative Disorders 300.13), is a rare psychiatric disorder
characterized by reversible amnesia for personal identity, including the memories,
personality and other identifying characteristics of individuality. The state is
usually short-lived (hours to days), but can last months or longer. Dissociative
fugue usually involves unplanned travel or wandering, and is sometimes
26
accompanied by the establishment of a new identity. After recovery from fugue,
previous memories usually return intact, however there is complete amnesia for
the fugue episode. Additionally, an episode is not characterized as a fugue if it can
be related to the ingestion of psychotropic substances, to physical trauma, to a
general medical condition, or to psychiatric conditions such as delirium, dementia,
bipolar disorder or depression. Fugues are usually precipitated by a stressful
episode, and upon recovery there may be amnesia for the original stressor
(Dissociative Amnesia)
Clinical definition
The etiology of the fugue state is related to Dissociative Amnesia, (DSM-IV Codes
300.12) which has several other subtypes: Selective Amnesia, Generalised Amnesia,
Continuous Amnesia, Systematised Amnesia, in addition to the subtype
Dissociative Fugue.
As the person experiencing a Dissociative Fugue may have recently suffered the
reappearance of an event or person representing an earlier life trauma, the
emergence of an armoring or defensive personality seems to be for some, a logical
apprehension of the situation.
Therefore, the terminology fugue state may carry a slight linguistic distinction
from Dissociative Fugue, the former implying a greater degree of motion. For the
27
purposes of this article then, a fugue state would occur while one is acting out a
Dissociative Fugue.
One or more episodes of amnesia in which the inability to recall some or all of
one's past and either the loss of one's identity or the formation of a new identity
occur with sudden, unexpected, purposeful travel away from home.
When in a fugue, people disappear from their usual routine and may
assume a new identity, forgetting all or some of their usual life.
28
Usually, doctors make the diagnosis by reviewing the history and collecting
information about the circumstances before travel, the travel itself, and the
establishment of an alternate life.
Usually, fugues last only hours or days, then resolve on their own.
Dissociative fugue affects about 2 of 1,000 people in the United States. It is much
more common among people who have been in wars, accidents, or natural
disasters.
Causes
Dissociative fugue is often mistaken for malingering because both conditions may
give people an excuse to avoid their responsibilities (as in an intolerable marriage),
to avoid accountability for their actions, or to reduce their exposure to a known
hazard, such as a battle. However, dissociative fugue, unlike malingering, occurs
spontaneously and is not faked.
Many fugues seem to represent disguised wish fulfillment (for example, an escape
from overwhelming stresses, such as divorce or financial ruin). Other fugues are
related to feelings of rejection or separation, or they may develop as an alternative
to suicidal or homicidal impulses.
Symptoms
29
A fugue may last from hours to weeks, months, or occasionally even longer. People
in a fugue state, having lost their customary identity, usually disappear from their
usual haunts, leaving their family and job. If the fugue is brief, they may appear
simply to have missed some work or come home late. If the fugue lasts several days
or longer, people may travel far from home and begin a new job with a new
identity, unaware of any change in their life.
Treatment
Most fugues last for hours or days, then disappear on their own.
30
However, efforts to restore memories of what happened during the fugue itself are
usually unsuccessful.
A therapist may help people explore their patterns of handling the types of
situations, conflicts, and moods that triggered the fugue to prevent subsequent
fugues
Diagnosis
A doctor may suspect dissociative fugue when people seem confused about their
identity or are puzzled about their past or when confrontations challenge their
new identity or absence of one. The doctor carefully reviews symptoms and does a
physical examination to exclude physical disorders that may contribute to or cause
memory loss. A psychologic examination is also done. Sometimes dissociative
fugue cannot be diagnosed until people abruptly return to their pre-fugue identity
and are distressed to find themselves in unfamiliar circumstances. The diagnosis is
usually made retroactively when a doctor reviews the history and collects
information that documents the circumstances before people left home, the travel
itself, and the establishment of an alternative life.
Case studies
Agatha Christie disappeared on 3 December 1926 only to reappear eleven days later
in a hotel in Harrogate, apparently with no memory of the events which happened
during that time span.
Jody Roberts, a reporter for the Tacoma News Tribune, went missing in 1985, only
to be found 12 years later in Sitka, Alaska, living under the name of "Jane Dee
Williams." While there were some initial suspicions that she had been faking
amnesia, some experts have come to believe that she genuinely suffered a
protracted fugue state.
31
David Fitzpatrick, a sufferer of dissociative fugue disorder from the United
Kingdom, was profiled on Five's television series Extraordinary People. He entered
a fugue state on December 22, 2005, and is still working on regaining his entire
life's memories.
Hannah Upp, a teacher from New York, went missing on August 28, 2008. She was
rescued from the New York Harbor on September 16 with no recollection of the
time in between. The episode was diagnosed as dissociative fugue.
Depersonalization Disorder
32
Depersonalization disorder (DPD) is a dissociative disorder in which the
sufferer is affected by persistent or recurrent feelings of depersonalization and/or
derealization. The symptoms include a sense of automation, going through the
motions of life but not experiencing it, feeling as though one is in a movie, feeling
as though one is in a dream, feeling a
disconnection from one's body; out-of-
body experience, a detachment from one's
body, environment and difficulty relating
oneself to reality.
33
distinguish between their own internal experiences and the objective reality of the
outside world. Sufferers are able to distinguish between reality and fantasy, during
episodic and continuous depersonalization, and do not represent a risk to society
since their grasp on reality remains stable at all times.
History
The word depersonalization itself was first used by Henri Frédéric Amiel in The
Journal Intime. The July 8, 1880 entry reads:
"I find myself regarding existence as though from beyond the tomb, from another
world; all is strange to me; I am, as it were, outside my own body and individuality; I
am depersonalized, detached, cut adrift. Is this madness?"
34
experiences that are difficult to articulate in words. Pierre Janet approached the
theory by pointing out his patients with clear sensory pathology did not complain
of symptoms of unreality, and that those who suffered from depersonalization
were normal from a sensory viewpoint.
Symptoms
Some of the more common factors that exacerbate dissociative symptoms are
negative effects, stress, subjective threatening social interaction, and unfamiliar
environments. Factors that tend to diminish symptoms are comforting
interpersonal interactions, intense physical or emotional stimulation, and
35
relaxation. Factors identified as relieving symptom severity such as diet, exercise,
alcohol and fatigue, are listed by others as worsening symptoms.
Fears of going crazy, brain damage, and losing control are common complaints.
Individuals report occupational impairments as they feel they are working below
their ability, and interpersonal troubles since they have an emotional
disconnection from those they care about. Neuropsychological testing has shown
deficits in attention, short-term memory and spatial-temporal reasoning.
Depersonalization disorder is associated with cognitive disruptions in early
perceptual and attentional processes.
Diagnosis
The diagnosis of DPD can be made with the use of the following interviews and
scales: The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-
D) is widely used, especially in research settings. This interview takes about 30
minutes to 1.5 hours, depending on individual's experiences.
36
been used in hundreds of dissociative studies, and can detect depersonalization
and derealization experiences.
DSM-IV-TR criteria
The diagnostic criteria defined in section 300.6 of the Diagnostic and Statistical
Manual of Mental Disorders are as follows:
37
1. Derealization, experiencing the external world as strange or unreal.
Etiology
38
with emotional regulation. In a similar test of emotional memory,
depersonalization disorder patients did not process emotionally salient material in
the same way as healthy controls. In a test of skin conductance responses to
unpleasant stimuli, the subjects showed a selective inhibitory mechanism on
emotional processing.
Epidemiology
Men and women are diagnosed in equal numbers with depersonalization disorder.
A 1991 study on a sample from Winnipeg, Manitoba estimated the prevalence of
depersonalization disorder at 2.4% of the population. A 2008 review of several
studies estimated the prevalence between 0.8% and 2%. This disorder is episodic
in about one-third of individuals, with each episode lasting from hours to months
at a time. Depersonalization can begin episodically, and later become continuous
at constant or varying intensity.
Onset is typically during the teenage years or early 20s, although some report
being depersonalized as long as they can remember, and others report a later
onset. The onset can be acute or insidious. With acute onset, some individuals
remember the exact time and place of their first experience of depersonalization.
This may follow a prolonged period of severe stress, a traumatic event, an episode
of another mental illness, or drug use. Insidious onset may reach back as far as can
be remembered, or it may begin with smaller episodes of lesser severity that
gradually become stronger. Patients with drug-induced depersonalization do not
appear to be a clinically separate group from those with a non-drug precipitant.
39
Relation to psychiatric disorders
Treatment
40
particular.[4] Benzodiazepines are not known to reduce dissociative symptoms,
however they do target the often co-morbid anxiety and stress experienced by
those with DPD, and thus lead to global improvement. To date no clinical trials
have studied the effectiveness of benzodiazepines.
Naloxone, an antagonist used primarily for the treatment of opiate overdose, was
used in a pilot study in 11 patients with chronic DPD. Of the 11 patients, three
experienced complete remission, and seven had marked improvement of
depersonalization symptoms. The study only reported immediate treatment
results, which makes the efficacy of continued treatment unknown. Naloxone can
only be administered intravenously, which makes long-term treatment difficult.
Naltrexone was used in a preliminary study in 14 individuals with DPD.
Participants were treated for 6–10 weeks, at a fairly high average dose of 120
milligrams per day. Three individuals were very much improved, another one was
much improved, and on average a 30% decrease in depersonalization symptoms
were reported. In another study in borderline personality disorder, doses of 200
milligrams per day of naltrexone was reported to decrease general dissociative
symptoms over a 2-week period of treatment.
41
Society and culture
42
Dissociative Identity
Disorder
Dissociative identity disorder is a psychiatric
diagnosis that describes a condition in which a person displays multiple distinct
identities or personalities (known as alter egos or alters), each with its own pattern
of perceiving and interacting with the environment. In the International Statistical
Classification of Diseases and Related Health Problems the name for this diagnosis
is multiple personality disorder. In both systems of terminology, the diagnosis
requires that at least two personalities routinely take control of the individual's
behavior with an associated memory loss that goes beyond normal forgetfulness;
in addition, symptoms cannot be the temporary effects of drug use or a general
medical condition.
There is a great deal of controversy surrounding the topic. There are many
commonly disputed points about DID. These viewpoints critical of DID can be
quite varied, with some taking the position that DID does not actually exist as a
valid medical diagnosis, and others who think that DID may exist but is either
always or usually an adverse side effect of therapy. DID diagnoses appear to be
almost entirely confined to the North American continent; reports from other
continents are at significantly lower rates
43
Multiple mannerisms, attitudes and
beliefs that are not similar to each
other
Unexplainable headaches and other
body pains
Distortion or loss of subjective time
Comorbidity
Depersonalization
Derealization
Severe memory loss
Depression
Flashbacks of abuse/trauma
Unexplainable phobias
Sudden anger without a justified cause
Lack of intimacy and personal connections
Frequent panic/anxiety attacks
Auditory hallucinations of the personalities inside their mind
Causes
44
patients report child abuse. People diagnosed with DID often report that they
have experienced severe physical and sexual abuse, especially during their
childhood. Several psychiatric rating scales of DID sufferers suggested that DID is
strongly related to childhood trauma rather than to an underlying
electrophysiological dysfunction.
Others believe that the symptoms of DID are created iatrogenically by therapists
using certain treatment techniques with suggestible patients, but this idea is not
universally accepted. Skeptics have observed that a small number of therapists are
responsible for diagnosing the majority of individuals with DID; that patients do
not report sexual abuse or manifest alters until after treatment has begun; and the
alternative explanation of the "alters" being rule-governed social roles rather than
separate personalities.
Diagnosis
45
Diagnosis should be performed by a psychiatrist or psychologist who may use
specially designed interviews (such as the SCID-D) and personality assessment
tools to evaluate a person for a dissociative disorder.
Screening
The SCID-D may be used to make a diagnosis. This interview takes about 30 to 90
minutes depending on the subject's experiences.
Differential diagnoses
46
Conditions which may present with similar symptoms include borderline
personality disorder, and the dissociative conditions of dissociative amnesia and
dissociative fugue. The clearest distinction is the lack of discrete formed
personalities in these conditions. Malingering may also be considered, and
schizophrenia, although those with this last condition will have some form of
delusions, hallucinations or thought disorder.
History
Before the 19th century, people exhibiting symptoms similar to those were believed
to be possessed.
The 19th century saw a number of reported cases of multiple personalities which
Rieber estimated would be close to 100. Epilepsy was seen as a factor in some cases,
and discussion of this connection continues into the present era.
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By the late 19th century there was a general acceptance that emotionally traumatic
experiences could cause long-term disorders which may manifest with a variety of
symptoms. These conversion disorders were found to occur in even the most
resilient individuals, but with profound effect in someone with emotional
instability like Louis Vivé (1863-?)who suffered a traumatic experience as a 13 year-
old when he encountered a viper. Vivé was the subject of countless medical papers
and became the most studied case of dissociation in the 19th century.
Between 1880 and 1920, many great international medical conferences devoted a
lot of time to sessions on dissociation. It was in this climate that Jean-Martin
Charcot introduced his ideas of the impact of nervous shocks as a cause for a
variety of neurological conditions. One of Charcot's students, Pierre Janet, took
these ideas and went on to develop his own theories of dissociation. One of the
first individuals diagnosed with multiple personalities to be scientifically studied
was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American
neurologist Morton Prince studied Fowler between 1898 and 1904, describing her
case study in his 1906 monograph, Dissociation of a Personality. Fowler went on to
marry one of her analyst's colleagues.
In the early 20th century interest in dissociation and multiple personalities waned
for a number of reasons. After Charcot's death in 1893, many of his so-called
hysterical patients were exposed as frauds, and Janet's association with Charcot
tarnished his theories of dissociation. Sigmund Freud recanted his earlier
emphasis on dissociation and childhood trauma.
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increased suspicion of DID was the decline of interest in dissociation as a
laboratory and clinical phenomenon.
Starting in about 1927, there was a large increase in the number of reported cases
of schizophrenia, which was matched by an equally large decrease in the number
of multiple personality reports. Bleuler also included multiple personality in his
category of schizophrenia. It was concluded in the 1980s that DID patients are
often misdiagnosed as suffering from schizophrenia.
Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde is known for its
portrayal of a split personality
The highly influential book Sybil was published in 1974, which popularized the
diagnosis through a detailed discussion of the problems and treatment of the
pseudonymous Sybil. Six years later, the diagnosis of multiple personality disorder
appeared in the DSM III. Controversy over the iconic case has since arisen, with
some calling Sybil's diagnosis the result of iatrogenic therapeutic methods while
others have defended the treatment and reputation of Sybil's therapist, Cornelia B.
Wilbur. As media coverage spiked, diagnoses climbed. There were 200 reported
cases of DID as of 1980, and 20,000 from 1980 to 1990. Joan Acocella reports that
49
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.
Controversy
DID is a controversial diagnosis and condition, with much of the literature on DID
being generated and published in North America, to the extent that it was
regarded as a phenomenon confined to that continent. Even within North
American psychiatrists there is a lack of consensus regarding the validity of DID.
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.
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 DID 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-addressed, the categorization over the
years.
The second edition of the DSM referred to this diagnostic profile as multiple
personality disorder. The third edition grouped MPD in with the other four major
dissociative disorders. The current edition, the DSM-IV-TR, categorizes the
disorder as dissociative identity disorder (DID). The ICD-10 (International
50
Statistical Classification of Diseases and Related Health Problems) continues to list
the condition as multiple personality disorder.
In a review, Joel Paris offered three possible causes for the sudden increase in
people diagnosed with DID:
Paris believes that the first possible cause is the most likely.
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. There are several main points of disagreement over
the diagnosis.
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.
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)
51
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.
Development theory
Physiological findings
52
of recording, rather than some inherent difference between the brains of people
diagnosed with DID. Brain imaging studies have corroborated the transitions of
identity in some DID sufferers. A link between epilepsy and DID has been
postulated but this is disputed. Some brain imaging studies have shown differing
cerebral blood flow with different alters, and distinct differences overall between
subjects with DID and a healthy control group. 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
Treatment of DID may attempt to reconnect the identities of disparate alters into a
single functioning identity. In addition or instead, treatment may focus on
symptoms, to relieve the distressing aspects of the condition and ensure the safety
of the individual. Treatment methods may include psychotherapy and medications
for comorbid disorders. Some behavior therapists initially use behavioral
treatments such as only responding to a single identity, and using more traditional
therapy once a consistent response is established. It has been stated that treatment
recommendations that follow from models that do not believe in the traumatic
origins of DID might be harmful due to the fact that they ignore the posttraumatic
symptomatology of people with DID.
Prognosis
DID does not resolve spontaneously, and symptoms vary over time. Individuals
with primarily dissociative symptoms and features of posttraumatic stress disorder
normally recover with treatment. Those with comorbid addictions, personality,
mood, or eating disorders face a longer, slower, and more complicated recovery
53
process. Individuals still attached to abusers face the poorest prognosis; treatment
may be long-term and consist solely of symptom relief rather than personality
integration. Changes in identity, loss of memory, and awaking in unexplained
locations and situations often leads to chaotic personal lives. [2] Individuals with the
condition commonly attempt suicide.[13]
Epidemiology
The DSM does not provide an estimate of incidence; however the number of
diagnoses of this condition has risen sharply. A possible explanation for the
increase in incidence and prevalence of DID over time is that the condition was
misdiagnosed as schizophrenia, bipolar disorder, or other such disorders in the
past; another explanation is that an increase in awareness of DID and child sexual
abuse has led to earlier, more accurate diagnosis. Other clinicians believe that DID
is an iatrogenic condition overdiagnosed in highly suggestive individuals, though
there is disagreement over the ability of the condition to be induced by hypnosis.
Figures from psychiatric populations (inpatients and outpatients) show a wide
diversity from different countries.
Country Prevalence
India 0.015%
Switzerland 0.05-0.1%
China 0.4%
Germany 0.9%
The Netherlands 2%
U.S. 10%
U.S. 6-8%
U.S. 6-10%
Turkey 14%
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Figures from the general population show less diversity:
Country Prevalence
Canada 1%
Turkey (male) 0.4%
Turkey 1.1%
(female)
Co morbidity
55