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Dissociative identity disorder



Dissociative identity disorder
Classification & external resources
ICD-10 F44.8
ICD-9 300.14
MeSH D009105

Dissociative identity disorder (DID), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), is a mental illness in which a single person displays multiple distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment.[1] 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, and symptoms are not due to substance abuse or medical condition. Earlier versions of the DSM named the condition multiple personality disorder (MPD), which is still used by the ICD-10.

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.[2][3][4] Even within North American psychiatrists there is a lack of consensus regarding the validity of DID.[5][6] Practitioners who do accept DID as a valid disorder have produced an extensive amount of 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.[4][7]

Additional recommended knowledge

Contents

Signs and symptoms

Individuals 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:[8]

Patients may experience an extremely broad array of other symptoms that resemble epilepsy, schizophrenia, anxiety, mood, posttraumatic stress, personality and eating disorders, with frequent mis-diagnoses and ineffective treatment.[8] Patients may experience auditory hallucinations of the various alters conversing, and may be mis-diagnosed as psychotic as a result. Changes in identity, loss of memory and awaking in unexplained locations and situations often leads to chaotic personal lives.[8]

Causes

It is believed that Dissociative Identity Disorder is caused by the interaction of overwhelming stress, insufficient nurturing during childhood and an innate ability to dissociate memories or experiences from consciousness.[8] Often the stress is rooted in prolonged childhood abuse, with an extremely high (97-98%) proportion of patients reporting abuse.[9] The DSM-IV TR states that people with DID often report that they have experienced severe physical and sexual abuse, especially during their childhood.[10] Reports by people with Dissociative Identity Disorder of their past physical and sexual abuse are often confirmed by objective evidence.[10] People responsible for the acts of sexual and physical abuse might be prone to distort or deny their behavior.[10]

Pathophysiology

Reviews of the literature have discussed the findings of various psychophysiologic investigations of DID.[11][12] Many of the investigations include testing and observation in the one person but with different alters. Different alter states have shown distinct physiological markers[13] and some EEG studies have shown distinct differences between alters in some subjects,[14][15] while other subjects' patterns were consistent across alters.[16] 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 persons with multiple personalities and those of persons with single personalities.[17] One EEG study comparing DID with hysteria showed differences between the two diagnoses.[18] A postulated link between epilepsy and DID has been disputed by a number of authors.[19][20] Some brain imaging studies have shown differing cerebral blood flow with different alters.[21][22][23] and distinct differences overall between subjects with DID and a healthy control group.[24] 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.[25] This study also found smaller amygdala volumes. Studies have demonstrated various changes in visual parameters between alters.[26][27][28] One twin study showed hereditable factors were present in DID.[29]

Diagnosis

The diagnostic criteria in DSM-IV Dissociative disorders section 300.14 require:

  • 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 and self.
  • At least two of these identities or personality states recurrently take control of the person's behavior.
  • Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
  • The disturbance 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). In children, the symptoms are not attributable to imaginary playmates or other fantasy play.[1] A patient history, x-rays, blood tests and other procedures can be used to eliminate symptoms being due to traumatic brain injury, medication, sleep deprivation or intoxicants, all of which can mimic symptoms of DID.[30]

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.[30]

Screening

The SCID-D[31] 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)[32] is a highly structured interview which discriminates between various DSM-IV diagnoses. The DDIS can usually be administered in 30-45 minutes.

The Dissociative Experiences Scale (DES)[33] is a simple, quick, and validated[34] 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[35] and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D[31] diagnoses and a cutoff of 20 missed 25%.[36] The reliability of the DES in non-clinical samples has been questioned.[37]

Treatment

Treatment of DID may attempt to 'reconnect' the identities of the disparate alters into a single functioning identity and/or may be symptomatic 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.[30] Some behavior therapists initially use behavioral treatments such only responding to a single identity, and using more traditional therapy once a consistent response is established.[38]

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 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.[8]

Epidemiology

The true prevalence of the disorder is hard to determine; the DSM does not provide an estimate, and suggests different explanations for the sharp rise in incidence of DID. Possible reasons suggested for the increase in incidence and prevalence of DID over time include the condition being misdiagnosed as schizophrenia, bipolar or other such disorders in the past, and/or an increase in awareness of DID and child sexual abuse leading to earlier, more accurate diagnosis. Other clinicians believe that DID is overdiagnosed or iatrogenically induced in highly suggestive individuals by overzealous therapists,[1] though there is disagreement over the ability of the condition to be induced by hypnosis.[39] Figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries:

Country Prevalence Source study
India 0.015% Adityanjee et al (1989)[40]
Switzerland 0.05-0.1% Modestin (1992)[41]
China 0.4% Xiao et al (2006)[42]
Germany 0.9% Gast et al (2001)[43]
The Netherlands 2% Friedl & Draijer (2000)[44]
U.S. 10% Bliss & Jeppsen (1985)[45]
U.S. 6-8% Ross et al (1992)[46]
U.S. 6-10% Foote et al. (2006)[36]
Turkey 14% Sar et al (2007)[47]

Figures from the general population show less diversity:

Country Prevalence Source study
Canada 1% Ross (1991)[48]
China 0% Xiao et al (2006)[42]
Turkey (male) 0.4% Akyuz et al (1999)[49]
Turkey (female) 1.1% Sar et al (2007)[50]

History

An intense interest in spiritualism, parapsychology and hypnosis continued throughout the 19th and early 20th centuries,[3] 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.[51] Hypnosis, which was pioneered in the late 1700s by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists observed second personalities emerging during hypnosis and wondered how two minds could coexist.[3] Early cases of what would now be diagnosed as DID appeared at this time and were treated by hypnosis.[51][52] The 19th century saw a number of increasingly sophisticatedly reported cases of multiple personalities which Rieber[51] estimated would be close to 100. Epilepsy was seen as a factor in some cases[51] and discussion of this connection continues into the present era.[16][20]

By the late 19th century there was a general realization that emotionally traumatic experiences could cause long-term disorders which may manifest with a variety of symptoms.[53] Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation. [54] 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 developed his own theories of dissociation.[55]

In the early 20th century interest in dissociation and MPD waned for a number of reasons. After Charcot's death in 1893, many of his "hysterical" patients were exposed as frauds and Janet's association with Charcot tarnished his theories of dissociation.[3] Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.[3] Freud, a man who actively promoted his ideas and enlisted the help of others, won out over the "lone wolf" Janet who did not train students in a teaching hospital.[51] Psychologists found that science was hard to reconcile with a "soul" or an "unconscious". In 1910, Eugen Bleuler introduced the term "schizophrenia" to replace "dementia praecox" and 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 "caught on," especially in the United States.[56] A number of factors helped create a large climate of skepticism and disbelief.[54]Paralleling the increased suspicion of MPD was the decline of interest in dissociation as a laboratory and clinical phenomenon.[54]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.[54] Bleuer also included multiple personality in his category of schizophrenia.[54] It was found in the 1980's that MPD patients are often misdiagnosed as suffering from schizophrenia.[54]

The public, however, were 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[51]. In 1957, 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. Multiple Personality began to emerge as a separate disorder in the 1970's.[54] The dedication and hard work of initially a small number of clinicians, but later with increased cooperation and support, re-established MPD as a legitimate clinical disorder. [54] In 1974, the highly influential book Sybil was published and six years later the diagnosis of Multiple Personality Disorder was included in the DSM. As media coverage spiked, diagnoses climbed. There were 200 reported cases of MPD from 1880 to 1979, and 20,000 from 1980 to 1990.[57] Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995.[58] The majority of diagnoses are made in North America, particularly the United States, and in English-speaking countries more generally[59] with reports recently emerging from other countries.[40][41][42][43][44][47][49]

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[60]) 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[61].

The second edition of the DSM referred to this diagnostic profile as Multiple Personality Disorder. The third edition grouped Multiple Personality Disorder in with the other four major Dissociative Disorders. The current edition, the DSM-IV-TR, categorizes the disorder as Dissociative Identity Disorder. The ICD-10 (International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as Multiple Personality Disorder.

The MPD/DID epidemic in North America

Paris[62] in a review offered three possible causes for the sudden increase in people diagnosed with MPD/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 recognise 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 opines 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 (see Multiple personality controversy). Unlike other diagnostic categorizations, there is very little in the way of objective, quantifiable evidence for describing the disorder. This makes the disorder itself subjective, as well as its diagnosis.

The main points of disagreement are these:

  1. Whether MPD/DID is a real disorder or just a fad.
  2. If it is real, is the appearance of multiple personalities real or delusional?
  3. If it is real, whether it should it be defined in psychoanalytic terms.
  4. Whether it can, or should, be cured.
  5. Who should primarily define the experience—therapists, or those who believe that they have multiple personalities.

Cultural references

Main article: DID/MPD in fiction

DID is common in plot device in pop culture fiction. Notable examples of films and books involving DID include Fight Club, Sybil and The Three Faces of Eve.

A popular mis-conception is that the condition is an equivalent for schizophrenia. The term schizophrenia comes from root words for "split mind," but refers more to a fracture in the normal functioning of the brain rather than a division of the mind into several personalities.

See also

Notes

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This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Dissociative_identity_disorder". A list of authors is available in Wikipedia.
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