Talk:Dissociative identity disorder/ArticleSandbox

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

Dissociative Identity Disorder (formerly Multiple Personality Disorder) (DSM-IV Dissociative Disorders 300.14[1]).

Dissociative Identity Disorder (DID), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, is a mental condition whereby a single individual evidences two or more distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. The presumption is that at least two personalities may routinely take control of the individual's behavior. The diagnostic criteria also calls for some associated memory loss that goes beyond normal forgetfulness, often referred to as losing time or acute Dissociative Amnesia[2]. The symptoms of DID must occur independently of substance abuse or a more general medical condition in order to be diagnosed. Dissociative identity disorder was originally named Multiple Personality Disorder (MPD)[3], and, as referenced above, that name remains in the International Statistical Classification of Diseases and Related Health Problems.

Regardless of whether the diagnosis is termed Dissociative Identity Disorder or Multiple Personality Disorder, the condition is in no way related to schizophrenia (DSM-IV Schizophrenia and Other Psychotic Disorders), as is often believed by the public. The term schizophrenia comes from root words for "split mind," but refers more to a fracture in the normal functioning of the brain, than the personality. Separate from the diagnosis and controversy surrounding DID, dissociation is a demonstrated symptom of several psychiatric disorders, including Borderline Personality Disorder (DSM-IV Personality Disorders 301.83), Post-traumatic stress disorder (DSM-IV Anxiety Disorders 309.81[4]), and Complex Post Traumatic Stress Disorder, to name a few.

As a diagnosis, DID remains controversial, with many professional psychiatrists and commentators arguing that there is no empirical evidence to support the disorder, or its diagnosis. On the other hand, some psychiatrists contend that they have encountered cases that appear to confirm the existence of this condition [5], and some mental health institutions, such as McLean Hospital[6], have wards specifically designated for Dissociative Identity Disorder.

Contents

[edit] A definition of dissociation

Main article: Dissociation (psychology)

Dissociation is defined as a complex mental process that provides a coping mechanism for individuals confronting painful and/or traumatic situations. It is characterized by a disintegration of the ego. Ego integration, or more properly ego (core personality) integrity, can be defined as a person's ability to successfully incorporate external events or social experiences into their perception, and to then present themselves consistently across those events or social situations. A person unable to do this successfully can experience emotional dysregulation[7], as well as a potential collapse of ego integrity. In other words, this state of emotional dysregulation is, in some cases, so intense that it can precipitate ego dis-integration, or what, in extreme cases, has come to be referred to diagnostically as dissociation.[8]

Dissociation describes a collapse in ego integrity so profound that the personality is considered to break apart.[citation needed] For this reason, dissocation is often referred to as splitting or altering. Less profound presentations of this condition are often referred to clinically as disorganization or decompensation. The difference between a psychotic break and a dissociation, or dissociative break, is that, while someone who is experiencing a dissociation is technically pulling away from a situation that he or she cannot manage, some part of the person remains connected to reality.[citation needed]

Because the person suffering a dissociation does not completely disengage from reality, she or he may appear to have multiple personalities to deal with different situations. When an alter cannot cope with stress, the consciousness of the person is believed to be given over to another personality to eliminate the trigger or pressure causing the stress.[9]

Dissociation is not sociopathic or compulsive. The biological stress caused by the original trauma is relieved by partially shunting the emotional response, which causes the reptilian complex to learn to dissociate reactively.[citation needed] This makes recovery from DID a matter of re-training the reptilian complex rather than a function of the more social neo-cortex.[dubious – discuss] Because the trigger is biological stress rather than specific external events, the exact causes of later reactive dissociation are difficult to trace to events.

[edit] Symptoms

Patients often exhibit a wide array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic, mood psychosis and seizure disorders. Symptoms of this particular disorder can include:

  • depression
  • anxiety (sweating, rapid pulse, palpitations)
  • phobias
  • panic attacks
  • physical symptoms (severe headaches or other bodily pain)
  • fluctuating levels of function, from highly effective to disabled
  • time distortions, time lapse, and Dissociative Amnesia
  • sexual dysfunction
  • eating disorders
  • post traumatic stress
  • suicidal preoccupations and attempts
  • episodes of self-mutilation
  • psychoactive substance use/abuse[10]

Other symptoms may include: Depersonalization, which refers to feeling unreal, removed from one's self, and detached from one's physical and mental processes. The patient feels like an observer of his life and may actually see himself as if he were watching a movie. Derealization refers to experiencing familiar persons and surroundings as if they were unfamiliar and strange or unreal.

Again, doctors must be careful not to assume that a client has MPD or DID simply because they exhibit some or all of these symptoms. For example, someone may have severe PTSD and self mutilate with suicidal ideas, which are two of the symptoms listed above, but in order for DID to be diagnosed, there must be two or more distinctly present personalities.

Persons with dissociative identity disorder are often told of things they have done but do not remember and of notable changes in their behavior. They may discover objects, productions, or handwriting that they cannot account for or recognize; they may refer to themselves in the first person plural (we) or in the third person (he, she, they); and they may have amnesia for events that occurred between their mid-childhood and early adolescence. Amnesia for earlier events is normal and widespread.

[edit] Causes/etiology

Although many experts dispute the existence of this controversial diagnosis, Dissociative Identity Disorder has been attributed by some to the interaction of several factors: overwhelming stress, dissociative capacity (including the ability to uncouple one's memories, perceptions, or identity from conscious awareness), the enlistment of steps in normal developmental processes as defenses, and, during childhood, the lack of sufficient nurturing and compassion in response to hurtful experiences or lack of protection against further overwhelming experiences[11]. Children are not born with a sense of a unified identity — it develops from many sources and experiences. In overwhelmed children, its development is obstructed, and many parts of what should have blended into a relatively unified identity remain separate. North American studies show that 97 to 98% of adults with dissociative identity disorder report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with dissociative identity disorder and other closely related forms of Dissociative Disorders. Although these data establish childhood abuse as a major cause among North American patients (in some cultures, the consequences of war and disaster play a larger role), they do not mean that all such patients were abused or that all the abuses reported by patients with dissociative identity disorder really happened. Some aspects of some reported abuse experiences may prove to be inaccurate. Also, some patients have not been abused but have experienced an important early loss (such as death of a parent), serious medical illness, or other very stressful events. For example, a patient who required many hospitalizations and operations during childhood may have been severely overwhelmed but not abused, although parents helping people through these times can act as a preventative measure. [10]

Human development requires that children be able to integrate complicated and different types of information and experiences successfully. As children achieve cohesive, complex appreciations of themselves and others, they go through phases in which different perceptions and emotions are kept segregated. Each developmental phase may be used to generate different selves. Not every child who experiences abuse or major loss or trauma has the capacity to develop multiple personalities. Patients with dissociative identity disorder can be easily hypnotized. This capacity, closely related to the capacity to dissociate, is thought to be a factor in the development of the disorder. However, most children who have these capacities also have normal adaptive mechanisms, and most are sufficiently protected and soothed by adults to prevent development of dissociative identity disorder.[10]

[edit] Diagnosis

If symptoms seem to be present, the patient should first be evaluated by performing a complete medical history and physical examination. Diagnostic tests, such as X-rays and blood tests may be used to rule out physical illness or medication side effects as the cause of the symptoms. Certain conditions, including brain diseases, head injuries, drug and alcohol intoxication, and sleep deprivation, can lead to symptoms similar to those of Dissociative Disorders, including Dissociative Amnesia.

If no physical illness is found, the patient might be referred to a psychiatrist or psychologist who may use specially designed interviews and personality assessment tools to evaluate a person for a Dissociative Disorder.[12]

[edit] Diagnostic criteria (DSM-IV-TR)

In summary, the diagnostic criteria in DSM-IV Dissociative Disorders[13] section 300.14[1] of the Diagnostic and Statistical Manual of Mental Disorders require the occurrence of two or more personalities within the same individual, each of which during some time in the person's life is able to take control. This must be combined with extensive areas of memory loss that cannot be explained as within normal limits. The symptoms must not be better explained by substance use or another medical condition.

The personalities are often very different in nature and may represent extremes of what is contained in a normal person. Memories may be asymmetrical with dominant identities remembering more than passive identities.

[edit] Screening and diagnostic instruments

The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D)[14] may be used to make a diagnosis. This interview takes about 30 minutes to 1.5 hours, depending on the subject's experiences.

The Dissociative Disorders Interview Schedule (DDIS)[15] 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)[16] is a simple, quick, and validated[17] 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[16] and in one study a DES with a cutoff of 30 missed 46% of the positive SCID-D[14] diagnoses and a cutoff of 20 missed 25%.[18] The reliability of the DES in non-clinical samples has been questioned.[19]

[edit] Pathophysiology

Reviews of the literature have discussed the findings of various psychophysiologic investigations of DID.[20][21] Many of the investigations include testing and observation in the one person but with different alters. Different alter states show distinct physiological markers.[22] EEG studies have shown distinct differences between alters,[23][24] findings another study failed to replicate.[25] 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 normal persons.[26] One EEG study comparing DID with hysteria showed differences between the two diagnoses.[27] A postulated link between epilepsy and DID has been disputed by a number of authors.[28][29] Some brain imaging studies have shown differing cerebral blood flow with different alters[30][31] while another has failed to replicate this finding.[32] 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.[33] This study also found smaller amygdala volumes. Studies have demonstrated various changes in visual parameters between alters.[34][35][36] One twin study showed hereditable factors were present in DID.[37]

[edit] Treatment/management

The most common approach to treatment aims to relieve symptoms, to ensure the safety of the individual, and to reconnect the different identities into one well-functioning identity. There are, however, other equally respected treatment modalities that do not depend upon integrating the separate identities. Treatment also aims to help the person safely express and process painful memories, develop new coping and life skills, restore functioning, and improve relationships. The best treatment approach depends on the individual and the severity of his or her symptoms. Treatment is likely to include some combination of the following methods:

  • Psychotherapy[38] [39]: This kind of therapy for mental and emotional disorders uses psychological techniques designed to encourage communication of conflicts and insight into problems.
  • Cognitive therapy: This type of therapy focuses on changing dysfunctional thinking patterns.
  • Medication: There is no medication to treat the Dissociative Disorders themselves. However, a person with a Dissociative Disorder who also suffers from depression or anxiety might benefit from treatment with a medication such as an antidepressant or anti-anxiety medicine.
  • Family therapy: This kind of therapy helps to educate the family about the disorder and its causes, as well as to help family members recognize symptoms of a recurrence.
  • Expressive therapy such as art therapy or music therapy: These therapies allow the patient to explore and express his or her thoughts and feelings in a safe and creative way.
  • Clinical hypnosis: This is a treatment technique that uses intense relaxation, concentration and focused attention to achieve an altered state of consciousness or awareness[12]
  • Behavior therapy: As an increasing number of therapists view DID as iatrogenic, or caused by reinforcing treatment teams, new approaches have emerged. Current standards of care may involve requiring the patient respond to a single name, and refusing to speak with the patient if she or he is a different sex, age, or person than initially presented. As the patient begins to respond more consistently to a single name, and speak in the first person, more traditional therapy for trauma may begin. Though some dislike this approach or criticize it as disrespectful of the client, it is highly effective, and many published accounts confirm this approach. See Kohlenberg & Tsai's "Functional Analytic Psychotherapy" (1991) for a more detailed explanation of this approach.

[edit] Prognosis

Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and post traumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of serious psychiatric disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. They improve more slowly, and treatment may be either less successful or longer and more crisis-ridden. Patients in the third group not only have severe coexisting psychopathology but may also remain enmeshed with their alleged abusers. Treatment is often long and chaotic and aims to help reduce and relieve symptoms more than to achieve integration.[10]

[edit] Prevention/screening

Strategies to prevent the development of DID depend upon how the etiology of the disorder is perceived. Early childhood trauma is frequently attributed as an etiology of DID, and so from this viewpoint, prevention of childhood trauma should reduce the incidence of DID. Those who believe that DID is often caused by suggestions from the clinician to suggestible people, caution clinicians against contributing to the diagnosis.[40][41]

[edit] Epidemiology

The true prevalence of the disorder is hard to determine. The DSM notes the sharp rise in reported cases and states that, "Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been overdiagnosed in individuals who are highly suggestive." [42] The DSM does not give a figure. Reports in the literature are often given by advocates for the condition and figures from psychiatric populations (inpatients and outpatients) show a wide diversity from different countries: India (0.015% per year[43]), Switzerland (0.05%-0.1%[44]), China (0.4%[45]), Germany (0.9%[46]), The Netherlands (2%[47]), U.S. (6%,[48] Approx., 6-8%,[49] 10%[50]), and Turkey (14%[51]). Figures from the general population show less diversity: China (0%[45]), Turkey (0.4% for a general sample[52] and 1.1% for a female sample[51]), and Canada (1%[53]).

[edit] History

[edit] Defining the controversy

Main article: Multiple personality controversy

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[54]) 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[55]. Often regarded as a dynamic sub-symptomatology, it has become more frequent as an ancillary diagnosis, rather than a primary diagnosis.[56]

[edit] The DSM re-dress

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 MPD 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-dressed, the categorization over the years.

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.

[edit] Other positions

The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the patient, or a case of unconscious collusion on the part of the patient and the professional is considerable (see Multiple personality controversy). Unlike other diagnostic categorizations, there is very little in the way of objective, quantifiable evidence for describing the disorder. This makes the disorder itself subjective, as well as its diagnosis.

The main points of disagreement are:

  1. Whether MPD/DID is a real disorder or just a fad.
  2. If it is real, if 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.

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 [citation needed] 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.


[edit] Social impact

[edit] Notable cases

[edit] In popular culture

Main article: DID/MPD in fiction

DID/MPD is common in pop culture fiction. See DID/MPD in fiction for further information.

[edit] See also

[edit] References

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  2. ^ Understanding dissociative disorders ( Mind.org.uk )
  3. ^ Dissociative Identity Disorder: An Explanation of Treatment ( Jennifer Giangiacomo, 05 July 2007 )
  4. ^ Posttraumatic Stress Disorder ( DSM-IV 309.81, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition )
  5. ^ Working with Dissociative Identity Disorder ( ValerieSinason.com )
  6. ^ Dissociative Disorders and Trauma Program
  7. ^ Dissociation FAQs ( International Society for the Study of Trauma and Dissociation, www.isst-d.org )
  8. ^ Background to Dissociation ( The Pottergate Centre for Dissociation & Trauma )
  9. ^ Guidelines for Treating Dissociative Identity Disorder in Adults ( James A. Chu, MD, 2005 )
  10. ^ a b c d Merck.com The Merck Manual.
  11. ^ First Person Plural
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[edit] External links


[[Category:Dissociative disorders]] [[de:Dissoziative Identitätsstörung]] [[es:Trastorno de identidad disociativo]] [[fi:Dissosiatiivinen identiteettihäiriö]] [[fr:Trouble dissociatif de l'identité]] [[he:פיצול אישיות]] [[id:Kepribadian yang terpecah]] [[ja:解離性同一性障害]] [[nl:Dissociatieve identiteitsstoornis]] [[pl:Osobowość mnoga]] [[pt:Transtorno dissociativo de identidade]] [[ru:Множественная личность]] [[sv:Dissociativ identitetsstörning]] [[ur:تفارقی شناختی اضطراب]] [[zh:多重人格]]