Dissociative identity disorder

Not to be confused with Dissocial personality disorder.

"Split personality" redirects here. For other uses, see Split personality (disambiguation).

Dissociative Identity Disorder
Classification and external resources
ICD-10	F44.8
ICD-9	300.14
MeSH	D009105

Dissociative identity disorder is a psychiatric diagnosis and describes a condition in which a person displays multiple distinct identities (known as alters or parts), 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 (one may be the host) 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.^[1] DID is less common than other dissociative disorders, occurring in approximately 1% of dissociative cases,^[2] and is often comorbid with other disorders.^[3]

There is a great deal of controversy surrounding the topic of DID. The validity of DID as a medical diagnosis has been questioned, and some researchers have suggested that DID may exist primarily as an iatrogenic adverse effect of therapy.^{[4][5][6][7][8]} DID is diagnosed significantly more frequently in North America than in the rest of the world.^[9][10]

Signs and symptoms

Individuals diagnosed with DID demonstrate a variety of symptoms with wide fluctuations across time; functioning can vary from severe impairment in daily functioning to normal or high abilities. Symptoms can include:^[11]

• Multiple mannerisms, attitudes and beliefs which are not similar to each other
• Unexplainable headaches and other body pains
• Distortion or loss of subjective time ( a long time)
• Depersonalization
• Derealization
• Severe memory loss
• Depression
• Flashbacks of abuse/trauma
• Sudden anger without a justified cause
• Frequent panic/anxiety attacks
• Unexplainable phobias

Patients may experience an extremely broad array of other symptoms such as pseudoseizures that may appear to resemble epilepsy, schizophrenia, anxiety disorders, mood disorders, post traumatic stress disorder, personality disorders, and eating disorders.^[11]

Physiological findings

Reviews of the literature have discussed the findings of various psychophysiologic investigations of DID.^[12][13] Many of the investigations include testing and observation in a single person with different alters. Different alter states have shown distinct physiological markers^[14] and some EEG studies have shown distinct differences between alters in some subjects,^[15][16] while other subjects' patterns were consistent across alters.^[17]

Neuroimaging studies of individuals with dissociative disorders have found higher than normal levels of memory encoding and a smaller than normal parietal lobe.^[18]

Another study concluded that the differences involved intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of people diagnosed with DID.^[19] Brain imaging studies have corroborated the transitions of identity in some DID sufferers.^[20] A link between epilepsy and DID has been postulated but this is disputed.^[21][22] Some brain imaging studies have shown differing cerebral blood flow with different alters,^[23][24][25] and distinct differences overall between subjects with DID and a healthy control group.^[26]

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.^[27] This study also found smaller amygdala volumes. Studies have demonstrated various changes in visual parameters between alters.^[28][29][30] One twin study showed hereditable factors were present in DID.^[31]

Causes

This disorder is theoretically linked with the interaction of overwhelming stress, traumatic antecedents,^[32] insufficient childhood nurturing, and an innate ability to dissociate memories or experiences from consciousness.^[11] A high percentage of patients report child abuse.^[7][33] People diagnosed with DID often report that they have experienced severe physical and sexual abuse, especially during early to mid childhood.^[34] Several psychiatric rating scales of DID sufferers suggested that DID is strongly related to childhood trauma rather than to an underlying electrophysiological dysfunction.^[35]

Others believe that the symptoms of DID are created iatrogenically by therapists using certain treatment techniques with suggestible patients,^[4][6][7][8] but this idea is not universally accepted.^{[33][36][37][38][39][40]} Skeptics have observed that a small number of US therapists were responsible for diagnosing the majority of individuals with DID there, that patients did not report sexual abuse or manifest alters until after treatment had begun, and that the "alters" tended to be rule-governed social roles rather than separate personalities^[8] which is consistent with replacing the personalities-focused MPD term with the identities-focused DID term. Additionally in China with "virtually no popular or professional knowledge of DID (...)"^[41] where "contamination cannot exist"^[41] it has been concluded that "the findings are not consistent with (...) iatrogenic models (...)".

Development theory

It has been theorized that severe sexual, physical, and/or psychological trauma in childhood by a primary caregiver predisposes an individual to the development of DID. The steps in the development of a dissociative identity disorder are theorized to be as follows:

1. The child is harmed by a trusted caregiver and splits off the awareness and memory of the traumatic event to survive in the relationship.
2. The memories and feelings go into the subconscious and are experienced later in the form of a separate part of the self.
3. The process reoccurs at future traumatic events resulting in more parts of the self to develop, each containing different memories and performing different functions that are meant to keep the child safe and to allow them to form an attachment to the caregiver. Sometimes abusers attempt to do this deliberately, as in the case of the more morbid abusive group practices of various sects, or torture variations.
4. Dissociation becomes a coping mechanism for the individual when faced with further stressful situations.^[42]

Diagnosis

The diagnosis of dissociative identity disorder is defined by criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-II used the term multiple personality disorder, the DSM-III grouped the diagnosis with the other four major dissociative disorders, and the DSM-IV-TR categorizes it as dissociative identity disorder. The ICD-10 continues to list the condition as multiple personality disorder.

The diagnostic criteria in section 300.14 (dissociative disorders) of the DSM-IV require that an adult, for non-physiological reasons, be recurrently controlled by multiple discrete identity or personality states while also suffering extensive memory lapses.^[43] While otherwise similar, the diagnostic criteria for children requires also ruling out fantasy.

Diagnosis should be performed by a therapist, psychiatrist or psychologist clinically trained in the specific material who may use specially designed interviews (such as the SCID-D) and personality assessment tools to evaluate a person for a dissociative disorder.^[1]

The psychiatric history of individuals diagnosed with DID frequently but not always contains multiple previous diagnoses of various mental disorders and treatment failures.

The proposed diagnostic criteria for DID in the DSM-5 is:^[44]

1. Disruption of identity characterized by two or more distinct personality states (one can be the host) or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others, or reported by the patient.
2. Inability to recall important personal information, for everyday events or traumatic events, that is inconsistent with ordinary forgetfulness.
3. Causes clinically significant distress and impairment in social, occupational, or other important areas of functioning.
4. The disturbance is not a normal part of a broadly accepted cultural or religious practice and is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures). NOTE: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.

• • These specifiers are under consideration.

a) With pseudoseizures or other conversion symptoms b) With somatic symptoms that vary across identities

The proposed Criterion C is intended to "help differentiate normative cultural experiences from psychopathology." This phrase, which occurs in several other diagnostic criteria, is proposed for inclusion in 300.14 as part of a proposed merger of dissociative trance disorder with DID. For example, professionals would be able to take shamanism, which involves voluntary possession trance states, into consideration, and not have to diagnose those who report it as having a mental disorder.^[45][46]

Screening

The SCID-D^[47] may be used to make a diagnosis. This interview takes about 30 to 90 minutes depending on the subject's experiences.

The Dissociative Disorders Interview Schedule (DDIS)^[48] is a highly structured interview that discriminates among various DSM-IV diagnoses. The DDIS can usually be administered in 30–45 minutes.

The Dissociative Experiences Scale (DES)^[49] is a simple, quick, and validated^[50] questionnaire that has been widely used to screen for dissociative symptoms. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-20^[51] and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D^[47] diagnoses and a cutoff of 20 missed 25%.^[52] The reliability of the DES in non-clinical samples has been questioned.^[53] There is also a DES scale for children and DES scale for adolescents. One study argued that old and new trauma may interact, causing higher DID item test scores.^[32]

Differential diagnoses

Conditions which may be present with similar symptoms include borderline personality disorder, and the dissociative conditions of dissociative amnesia and dissociative fugue.^[54] 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.^[54]

Treatment

Treatment of DID may attempt to reconnect the identities of disparate alters into a single functioning identity with all its memories and experiences intact - functioning much like the normal brain. 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.^[1] 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.^[55] 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.^[38]

Prognosis

DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily dissociative symptoms and features of post traumatic stress disorder normally recover with treatment. Those with comorbid addictions, personality, mood, or eating disorders face a longer, slower, and more complicated recovery 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.^[11] Individuals with the condition commonly attempt suicide.^[3]

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 over diagnosed in highly suggestive individuals,^[56] though there is disagreement over the ability of the condition to be induced by hypnosis.^[36][37] Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:^[57]

Country	Prevalence in mentally ill populations	Source study
India	0.015%	Chiku et al. (1989)[58]
Switzerland	0.05 - 0.1%	Modestin (1992)[59]
China	0.4%	Xiao et al. (2006)[41]
Germany	0.9%	Gast et al. (2001)[60]
Netherlands	2%	Friedl & Draijer (2000)[61]
United States	10%	Bliss & Jeppsen (1985)[62]
United States	6 - 8%	Ross et al. (1992)[63]
United States	6 - 10%	Foote et al. (2006)[52]
Turkey	14%	Sar et al. (2007)[64]

Figures from the general population show less diversity:

Country	Prevalence	Source study
Canada	1%	Ross (1991)[65]
Turkey (male)	0.4%	Akyuz et al. (1999)[66]
Turkey (female)	1.1%	Sar et al. (2007)[67]

Dissociative identity disorder is diagnosed in a sizable minority of patients in drug abuse treatment facilities.^[7]

Comorbidity

Dissociative identity disorder frequently co-occurs with other psychiatric diagnoses, such as anxiety disorders (especially post-traumatic stress disorder-PTSD), mood disorders, somatoform disorders, eating disorders, as well as sleep problems and sexual dysfunction.^[3] Dissociative identity disorder has been found to more commonly occur with particular personality disorders including Avoidant Personality Disorder (76% co-morbidity), Self-defeating Personality Disorder (68% co-morbidity), Borderline Personality Disorder (53% co-morbidity) and Passive-Aggressive Personality Disorder (45% co-morbidity).^[68] Schizotypal Personality Disorder also had a 58% crossover with dissociative tendencies.^[68]

History

One of ten photogravure portraits of Louis Vivé published in Variations de la personnalité by Bourru and Burot.

Before the 19th century, people exhibiting symptoms similar to those were believed to be possessed.^[3]

An intense interest in spiritualism, parapsychology, and hypnosis continued throughout the 19th and early 20th centuries,^[10] running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings.^[69] Hypnosis, which was pioneered in the late 18th century by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists reported what they thought were second personalities emerging during hypnosis and wondered how two minds could coexist.^[10]

The 19th century saw a number of reported cases of multiple personalities which Rieber^[69] estimated would be close to 100. Epilepsy was seen as a factor in some cases,^[69] and discussion of this connection continues into the present era.^[17][21]

By the late 19th century there was a general acceptance that emotionally traumatic experiences could cause long-term disorders which might display a variety of symptoms.^[70] 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.^[71] 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.^[72] 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.^[72] Fowler went on to marry one of her analyst's colleagues.^[73]

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.^[10] Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.^[10]

In 1910, Eugen Bleuler introduced the term schizophrenia to replace dementia praecox. A review of the Index medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia became popular, especially in the United States.^[74] A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID was the decline of interest in dissociation as a laboratory and clinical phenomenon.^[71]

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.^[71] 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.^[71]

Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde is known for its portrayal of a split personality

The public, however, was exposed to psychological ideas which took their interest. Mary Shelley's Frankenstein, Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe had a formidable impact.^[69] In 1957, with the publication of the book The Three Faces of Eve and the popular movie which followed it, the American public's interest in multiple personality was revived. During the 1970s an initially small number of clinicians campaigned to have it considered a legitimate diagnosis.^[71]

Between 1968 and 1980 the term that was used for dissociative identity disorder was "Hysterical neurosis, dissociative type". The APA wrote: "In the dissociative type, alterations may occur in the patient's state of consciousness or in his identity, to produce such symptoms as amnesia, somnambulism, fugue, and multiple personality."^[75]

The highly influential book Sybil (which was purported to be true, but has since been identified as likely heavily fictionalized^[76]) was published in 1974, which popularized the diagnosis through a detailed discussion of the problems and treatment of the pseudonymous Sybil. An October, 2011 report on NPR included discussions with Debbie Nathan, author of the book "Sybil Exposed: The Extraordinary Story Behind the Famous Multiple Personality Case", and other psychology professionals, about the allegations that the "Sybil" story was, if not a fraud, then a case that involved questionable or duplicitous behavior by the patient, as well as by her doctor, who was interested in the theory and who wanted to believe this was an actual case and who may have been intent on making sure it would be seen as such, and also by the original "Sybil" book's author, who had a large amount of money involved in the book contract.^[77]

Six years following the publication of the book "Sybil", the diagnosis of multiple personality disorder appeared in the DSM III.^[3] Controversy over the iconic case has since arisen, with some calling Sybil's diagnosis the result of iatrogenic therapeutic methods^[78] while others have defended the treatment and reputation of Sybil's therapist, Cornelia B. Wilbur.^[79] As media coverage spiked, diagnoses climbed. There were 200 reported cases of DID as of 1980, and 20,000 from 1980 to 1990.^[80] Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995.^[81] The majority of diagnoses are made in North America, particularly the United States, and in English-speaking countries more generally^[82] with reports recently emerging from other countries.^{[41][58][59][60][61][64][66]}

Society and culture

Main article: Dissociative identity disorder in popular culture

Controversy

DID is a controversial diagnosis and condition, with much of the literature on DID still being generated and published in North America, to the extent that it was once regarded as a phenomenon confined to that continent.^[4][10] Even among North American psychiatrists there is a lack of consensus regarding the validity of DID.^[5][83] 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.^[84] 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.^[4][6] In China with "virtually no popular or professional knowledge of DID (...)"^[41] where "contamination cannot exist"^[41] it has been concluded that "the findings are not consistent with (...) iatrogenic models (...)".

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 Statistical Classification of Diseases and Related Health Problems) continues to list the condition as multiple personality disorder.

Psychiatrist Colin A. Ross has stated that based on documents obtained through freedom of information legislation, psychiatrists linked to Project MKULTRA claimed to be able to deliberately induce dissociative identity disorder using a variety of aversive techniques.^[85]

Over-representation in North America

In a review,^[9] Joel Paris offered three possible causes for the sudden increase in people diagnosed with DID:

1. The result of therapist suggestions to suggestible people, much as Charcot's hysterics acted in accordance with his expectations.
2. Psychiatrists' past failure to recognize dissociation being redressed by new training and knowledge.
3. Dissociative phenomena are actually increasing, but this increase only represents a new form of an old and protean entity: "hysteria".

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^[86]) 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.^[87]

See also

	Psychology portal
	Psychiatry portal

• Dissociation
• Dissociative identity disorder in popular culture
• Fugue state
• Identity formation
• Psychogenic amnesia
• Splitting (psychology)

Footnotes

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References

• Sadock, Benjamin J.; Sadock, Virginia A. (2002). Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams & Wilkins. ISBN 0781731836. 

Further reading

• Goettmann, B. A.; Greaves BG; Coons MP (1994). Multiple personality and dissociation, 1791-1992: a complete bibliography. Lutherville, MD: The Sidran Press. pp. 85. ISBN 0-9629164-5-5. http://boundless.uoregon.edu/cdm4/item_viewer.php?CISOROOT=/diss&CISOPTR=38. 

External links

• Dissociative identity disorder at the Open Directory Project
• International Society for the Study of Trauma and Dissociation