The Brain: Stress Response Activation and Managing Symptoms

James-Lange Theory of Emotions proposes that emotions are the brain’s interpretation of physiological responses to emotionally provocative stimuli. Darwin proposed that emotions played a significant role in the survival of the species and resulted from similar evolutionary processes as other behaviors and psychological functions did. For example, Emotions like fear invoke actions that either could attempt to overcome the source of fear through fight or run from the source through the flight. In this way, emotions help us process and respond to danger cues that aid in our survival. However, prolonged stress exposure and the constant activation of the Fight or Flight responses are associated with negative effects as well. 

Fight or Flight Response is provided by activity from the sympathetic branch of the autonomic nervous system. Fight or Flight Response is responsible for this biological process that prepares us for action in emergencies including producing stress hormones epinephrine, norepinephrine, and cortisol. In the anticipation of a sudden demand for energy needed to escape danger, a release of epinephrine induces glucose metabolism which in turn starts to metabolize nutrients stored within muscles to become accessible to provide energy. Norepinephrine is also released and increases blood flow to muscles by increasing the flow of blood from the heart (Carlson, 2009, p. 601).       

Norepinephrine is not just a stress hormone released in the body as it is also found secreted in the brain as a neurotransmitter (Carlson, 2009, p. 601). The amygdala is fundamental to emotional processes, especially those relating to fear. The amygdala is a structure located in the interior of temporal lobes (Argosy Online Universities Lecture, 2013). When exposed to stressors a stress response is activated in a pathway from the “central nucleus of the amygdala to the locus coeruleus”, provoking the release of norepinephrine from the brain. It is within the nucleus of the brain stem that the norepinephrine-secreting neurons are located (Carlson, 2009, p. 602). Corticotropin-releasing hormone activates the secretion of ACTH by the anterior pituitary gland in the brain, where it in turn also contributes to some of the emotional responses typically seen in stressful situations (Carlson, 2009, p. 611).

Cortisol, also called glucocorticoids, is a steroid secreted by the adrenal cortex, especially during experiences of stress, and is vital to survival (Carlson, 2009, p. 602). Cortisol is vital in the metabolism of protein and carbohydrates (Carlson, 2009, p. 602). Glucocorticoids have a specific function of helping with the endogenous decomposition of protein and converting it to glucose. This makes fats available for “energy, increase blood flow, and stimulates behavioral responsiveness by affecting the brain” (Carlson, 2009, p. 602). Glucocorticoids also affect the ability of the gonads to sense luteinizing hormone (LH) causing less endogenous production of sex steroid hormones (Carlson, 2009, p. 602). Long-term exposure to stress-induced glucocorticoids has been demonstrated to destroy neurons located in hippocampal formation which is largely associated with cognitive functions such as learning and memory (Carlson, 2009, p. 604). This cell death is caused by the decreases in the uptake of glucose and decreasing the reuptake of glutamate, causing extracellular glutamate which permits calcium to pass through NMDA receptors and kill neurons (Carlson, 2009, p. 604). While Glucocorticoids aid in vital functions prolonged exposure to stress-induced Glucocorticoids is associated with damage to “muscle tissue, steroid diabetes, infertility, inhibition of growth, inhibition of the inflammatory responses and acts to suppress the immune system” (Carlson, 2009).

Prolonged exposure to glucocorticoids works to suppress the immune system (Carlson, 2009, p. 610). Immune suppression from stress can put one at risk for upper respiratory infection and colds (Carlson, 2009, p. 610). Studies indicate that increases in the number of undesirable events and a decreases the number of desirable events in one's life lead to medical illness through immune’s suppression of the immunoglobulin, IgA, in mucous membranes of the nose, mouth, throat, and lungs (Carlson, 2009, p. 610). Immunoglobulin, IgA, is the primary defense against infectious microorganisms that enter the nose or mouth and is affected by mood (Carlson, 2009, p. 610-611). This risk would naturally be increased if one's immune system was already suppressed either by medication, illness, or age.

A stimulus that causes us psychological distress causes the emotions and feelings associated through increases in stress hormones from activation of the “Fight or Flight Response” (Carlson, 2009).  The stress response produces an increase in epinephrine and cortisol which will assist in our escape, but escape from certain life events is not always possible. This leaves the person who is suffering from prolonged exposure to stress at risk for a variety of psychological symptoms, physical illnesses, and brain damage from stress hormone toxicity. Prolonged stress is also associated with increased blood pressure from the increases in stress hormones Norepinephrine and Epinephrine. Over time contributes to cardiovascular disease and a variety of other illnesses like stress disorders. While prolonged overexposure to stress-induced Cortisol or Glucocorticoids is associated with damage to “muscle tissue, steroid diabetes, infertility, inhibition of growth, inhibition of the inflammatory responses, and suppression of the immune system” (Carlson, 2009, p. 603). 

Prolonged exposure to stress can cause brain abnormalities, specifically in the hippocampus and amygdala formations, as seen in studies of patients with PTSD and Stress disorders (Carlson, 2009, p. 607). PTSD is a psychological disorder that results from exposure to a situation of extreme danger and stress and includes distressing symptoms like recurrent dreams or intrusive recollections of trauma that interfere with social activities and cause a feeling of hopelessness (Carlson, 2009, p. 606). The hippocampus plays a vital part in contextual learning including participating in the recognition of the context in which traumatic experiences occur and later helping one distinguish safe from dangerous context (Carlson, 2009, p. 607). One hypothesis suggests that after a person is attacked by something a traumatic trigger is created and stored with traumatic stimuli, however, because of the damage to the hippocampus the ability to distinguish actual traumatic stimuli from similar stimuli is impaired resulting in the activation of the amygdala and the trigger of an emotional response in the face of similar stimuli (Carlson, 2009, p. 607). The prefrontal cortex can exert an inhibitory effect on the amygdala and suppress emotional reactions including the loss of conditioned emotional responses like fear (Carlson, 2009, p. 607). Evidence suggests that actions from prefrontal cortex inhibiting the activity of the amygdala may be liable for emotional reactions and psychological symptoms such as difficulty falling or staying asleep, irritability, outbursts of anger, difficulty in concentrating, and heightened reactions to sudden noises or movements found in persons with PTSD (Carlson, 2009, p. 607-608).

             The above changes in physiological fight or flight response to stress and its effects on cognitive or emotional changes would be similar in most persons who were living under these same stressors, what would likely differ is the length of duration before the onset of symptoms that impair function. If the same stressor was being experienced by a person of the opposite sex or someone much older or younger there might be some differences in how they react emotionally. For example, men may be less tearful and frightened and react with more anger and hostility, while an older or wiser person may feel unabashed and a younger person may be completely depressed and express with hyperactivity and impulsivity, instead of displaying fear and tears. How someone reacts to a stressor is largely based on their ability and resources to deal with the problems, how much social support they have, their previous trauma experiences, personality, temperament, coping skill and lastly, how long the stressor persists.

The four most important behavioral strategies I would suggest one implement immediately to reduce the effects of stress on my body is cared for themselves by making sure they get adequate sleep, sun, nutrition, and exercise.

Getting proper nutrition is important because nutrients play a vital role in neurotransmitter metabolism. Vitamin deficiencies are often found in subjects with depression and being properly nourished supplies the body with minerals such as calcium, iron, magnesium, selenium, and zinc that aid in preventing depression, irritability, and mood swings (Masley, 2013). One of the most important things one can do to combat stress is to work on making sure they have a stock of healthy ready to eat items handy.

Exercise has been shown to increase serotonin function, so exercising can help induce a positive mood (Young, 2007). Several studies have confirmed a relationship between serotonin and mood, indicating that less serotonin correlates with more negative moods (Young, 2007). Studies that have researched exercise and the relationship with mood concluded that exercise has antidepressant and anxiolytic effects, plus increases brain serotonin function (Young, 2007).

Get more sunlight, which can help increase serotonin levels and improve mood.  A studied has demonstrated a “positive correlation between serotonin synthesis and the hours of sunlight received” that day; therefore, increasing my sunlight can also help me fight feelings of depression (Young, 2007).

Why exactly the brain needs to sleep is perhaps poorly understood, but it is clear that decreases in sleep later results in poor cognitive function and psychological symptoms because sleep deprivation impairs cerebral functioning (Carlson, 2009, p. 310). As the brain activity utilities glycogen as fuel for the neural activity it levels drop producing extracellular adenosine chemicals, which then accumulate prohibiting normal neural activity (Carlson, 2009). This chemical toxicity produces both the cognitive and emotional effects that are seen during sleep deprivation and the process that occurs during sleep helps restock glycogen for tomorrow.

Poor sleep results in poor cognitive performance because it is during sleep, particularly during slow-wave and REM state, that our brains restore cognitive function and process information (Carlson, 2009). Increases in mental activity, including dealing with stressors, would cause an increased need for slow-wave sleep to facilitate the consolidation of explicit memories (Carlson, 2009, p. 307). REM sleep is equally important and is believed to play a major role in the development and learning, particularly the consolidation of long-term memories and implicit memories (Carlson, 2009, p. 309). Decreased sleep also causes increases in highly reactive oxidizing agents called free radicals within the brain (Carlson, 2009, p. 307). During a process called oxidative stress, free radicals can bind with electrons from other molecules and damage the cells that they inhabit (Carlson, 2009, p. 307). The decreased metabolic rate during slow-wave sleep allows for the restorative mechanisms to eliminate free radicals before damage occurs (Carlson, 2009, p. 307). Clearly, getting enough regular sleep will improve my cognitive function and emotional well-being.

The most important skill one must demonstrate to implement these is time management.

References

Carlson, N. R. (2009). Physiology of Behavior, 10th Edition. Pearson Learning Solutions. VitalBook file.

Mills, H.  Reiss, N.  Dombeck, M. (2008). Cognitive Therapy Techniques for Stress Reduction.  MentalHelp.  Retrieved from http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=15667&cn=117

Masley, J. (February, March 2005). The role of exercise, nutrition, and sleep in the battle against depression. Mental Health Matters. 2(5,6). Gratiot Medical Center: An Affiliate of MidMichigan Health. http://fhpcc.com/PDFs/RolesAgainstDepression.pdf

Young, S. M. (2007). How To Increase Serotonin in the Human Brain Without Drugs. Journal of Psychiatry Neurosci. 2007 November; 32(6): 394–399. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077351/ 

Exploring Psychological Theories: Examining Gandhi with Adlerian Theory

Mahatma Striving for Success

Here we examine the life of Gandhi through the framework of Alder’s theory “Striving for Success or Superiority” and attempt to find what forces shaped Gandhi’s perceived inferiority, how they propelled his superiority striving and how he overcame his perceived inferiority. While examining the motivational influences of Gandhi’s through Alder’s framework the author will attempt to shed insight how he obtained his high level of superiority striving, as well as his goals, how they influenced his career choices, and how his unique style of life that helped him accomplish these goals.

In Alder’s (1956) theory “Striving for Success or Superiority” the central force behind human behavior is an innate human tendency to feel inferior and seek completion or wholeness through the creation, internalization and completion of one’s own fictional final goal.  Adler’s theory stated that although this functional goal is partly constructed out of the raw materials, such as those provided by genetics and sociocultural influences, it is actually created with creative power from one’s own subjective perceptions of reality (Feist, 2009). Alder’s theory argues that a person’s subjective perceptions shape their motivational influences, behavior, and creative power shapes their unified and self-consistent personality, which then develops into a person’s style of life (Feist, 2009).Alder’s (1956) suggest that in conjunction with the innate human tendency to be compelled by feelings of inferiority to gravitate towards completion or wholeness through success striving integral to development of healthy fictional goals that strive for success and social interests is a child’s parental attachment styles (Feist, 2009). Alder (1956) argues that while genetic components contribute to the potentiality of character and sociocultural factors contribute to the development of social interest, it is the type of love and nurturing that parental influences give that is the determining factor in the development of healthy objectives for success striving (Feist, 2009). Alder’s argues, that children who receive love and security from their parents nurturing and consequently semi-consciously set and pursue a final goal with superiority defined in terms of success and social interest (Feist, 2009).

When we examine the life Mohandas Karamchand Gandhi through this framework of Alder’s we would say that Gandhi would have been continually motivated to strive for success or superiority by the need to overcome inferiority feelings. Alder’s theory also suggested that as the youngest child of three siblings Gandhi would have been most likely to struggle with strong feelings of inferiority and lack a sense of independence. Alder would have argued that these innate feelings of inferiority and lack a sense of independence would have worked to motivate Gandhi throughout his life to exceed his older siblings. Gandhi’s observable inferiority or weakness could be that he was a mediocre Indian Hindu student part of lower caste social class in India (Progress Report, 2014). From this perspective, Gandhi may have chosen to be a lawyer and peace activist to overcome the feelings of inferiority he felt growing up middle-class yet subject to discrimination and oppression all over the world because he was an Indian, Hindu or part of the lower caste system. Thus we could assume that growing up with feelings of inferiority created by the oppression in the caste system a significant motivator in Gandhi’s adult choice to peacefully fight against colonialism, racial discrimination, economic exploitation, India's Independence, and human rights.

The history of Gandhi’s proclaims his parents were cultured and devout Hindu’s (The Progress Report, 2014). Gandhi himself, a cultured and devout Hindu, proclaimed his father “brave, incorruptible, and short-tempered and remembered his mother as a saint” (The Progress Report, 2014). Seemingly essential to the completion of his goals was Gandhi’s faith, which was largely influenced by his mother’s own devotion to her faith. Gandhi’s faith contributed significantly to his very unique style of life and altruistic philosophy.  His very unique style of life and altruistic philosophy helped him achieve great things primarily by allowing people see that this motivational intent was pure and good, thus increasing his social power. Consequently, central to the motivational forces that influenced Gandhi’s was the inferiority and fear he felt in times when he strayed from the principals of his religion and honesty. Early childhood experiences when Gandhi defied his faith, ate meat, stole from his brother and hid from his parents to cover his sins admittedly made Gandhi feel fear, anxiety, and likely supremely inferior as well.

Perhaps more significant than his rebellion from his faith and parents was the relief he felt from fear, anxiety, and inferiority when he confessed to his father. In Gandhi’s memoirs, he writes of time when he confessed a sin of theft against his brother to his father expecting to be rebuked with anger and violence and instead his father wept (The Progress Report, 2014). Gandhi later wrote, “Those pearl drops of love cleansed my heart and washed my sin away” (The Progress Report, 2014). Gandhi also proclaimed this “was his first insight into the impressive psychological power of ahimsa, or nonviolence” (The Progress Report, 2014). These moments with his father led to the insight into the power of ahimsa or nonviolence and led to the development of subjective perceptions that were extremely influential for young Gandhi. From Alder’s perspective, it was these early and influential moments with his parents that significantly contributed to the development of Gandhi unified and self-consistent style of life, honest convictions and non violent activism that left a mark of honor all over the world.

From Alder’s perspective, it was to overcome his perceived inferiority that Gandhi developed a style of life which was honest and non-violent and became a leader who acted out of social interest instead of for personal gain. The history of reflects that Gandhi utilized “Satya (truth) and Ahimsa (non-violence) in pursuit of truth (God), in its most pristine manifestations, justice and liberty for man” (Bhavan, 2004). From his actions in life, we can presume that primary fictional goal was finding equality for all people through honesty and non-violence. Although imprisoned several times, Gandhi lived to become the most renowned leader of Indian nationalism in British-ruled India when he utilized nonviolent civil disobedience to lead India to independence (Wikipedia, 2014). This monumental achievement inspired movements for civil rights and freedom across the world (Wikipedia, 2014). The long-term outcome of Gandhi’s striving is extremely motivating for many people including those who were directly affected by his actions, those indirectly affected and those who read about him now.

Differential Diagnosis: Misdiagnosis Narcolepsy

Narcolepsy is a neurological auto immune disorder in which the person is afflicted with various types of day and nighttime sleep disturbances because of abnormalities in rapid eye movement (REM) sleep. Because the rapid eye movement (REM) sleep is abnormal in narcolepsy it is sometimes defined as the loss of boundaries between wakefulness, non-REM sleep, and REM sleep (North Side Sleep Medicine, 2014).  According to the National Institute of Neurological Disorders and Stroke (2014) a common misconception is that people with narcolepsy sleep more than people without narcolepsy, when in fact the amount of sleep does not actually differ too much between the two. In reality, narcoleptics exhibit various types of both day and nighttime sleep disturbances and symptoms (NINDS, 2014).

The two primary symptoms in narcolepsy are Excessive daytime sleepiness (EDS) and cataplexy. Excessive daytime sleepiness, frequent daily sleep attacks or a need to take several naps during the day are all part of the clinical syndrome of narcolepsy. Another common symptom called cataplexy is usually brought on by strong emotions and includes temporary and sudden muscle weakness. While cataplexy makes the diagnosis easier to spot when recognized, Narcolepsy can exist without cataplexy or the patients may not know when or what the cataplexy is when it happens. Other patients may experience symptoms in the narcoleptic tetrad including Microsleep, Atonia or Sleep Paralysis, hypnagogic or hypnopompic hallucinations.

• Excessive daytime sleepiness (EDS)

• Cataplexy

• Microsleep

• Atonia or Sleep Paralysis

• Hypnagogic or hypnopompic hallucinations

A microsleep (MS) is a temporary and brief episode of sleep in which a person who is seemingly awake fails to respond to sensory input. During Microsleep episodes the narcoleptic often behaves automatically but without conscious awareness. These events can occur simultaneously with a blank stare, head snapping, and prolonged eye closure such as seen when person is fatigued, but trying to stay awake to perform a monotonous task like driving a car or watching a computer screen (Sleepdex, 2014).. Microsleep episodes are very brief tending to last anywhere from a few seconds to two minutes (Sleepdex, 2014). Often the person is unaware the microsleep occurred and because they happen with the eyes open they can be missed by the observer as well.

Atonia or Sleep Paralysis describes a sense of paralysis that occurs between wakefulness and sleep. During an episode of sleep paralysis the person is not able to move their body or limbs. Atonia is defined as lack of tone or energy; muscular weakness, especially in a contractile organ. When atonia happens during the transition from waking to sleep or from sleep to waking it is called sleep paralysis and the person is aware, but unable to move.

Hypnagogic Hallucinations are dreams like states that intrude on wakefulness and can cause visual, auditory, or touchable sensations. Hypnagogic Hallucinations can occur between waking and sleeping, usually at the onset of sleep, but can also occur about 30 seconds after a cataplectic attack.According to the University of Maryland Medical Center the visual hallucinations have been described as a "film running through the head" or as a waking dream with intrusive imagery commonly involving seeing colored forms that shift in size and shape (UMMC, 2014). Auditory hallucinations may include random sounds or elaborate melodies while tactile hallucinations can include feelings of rubbing, light touches or even levitation (UMMC, 2014).

Typically speaking individuals with narcolepsy have little to no difficulties falling asleep at night and slip into Rem sleep shortly after falling asleep. However, most narcoleptic s experience difficulties staying asleep (NINDS, 2014). Many Narcoleptics may have their sleep disrupted by insomnia, vivid dreaming, sleep talking, acting out while dreaming, as well as periodic leg movements (NINDS, 2014).

Disrupted Nocturnal Sleep Symptoms
o Insomnia
o Vivid dreaming
o Sleep talking
o Acting out while dreaming
o periodic leg movements while sleeping

Other peculiar behavior seen in narcoleptic s that may seem non specific include cognitive and behavioral symptoms such as forgetfulness, clumsiness, location disorientation, pauses or slows in speech or an inability to follow or maintain conversations.

Cognitive or Behavioral Symptoms (UMMC, 2014)

• Severe forgetfulness
• End up in a location different from the intended one.
• Jump from one unrelated topic to another or just trail off and stop talking altogether.
• Perform bizarre actions, such as putting socks in the refrigerator.
• Movements that suddenly becomes slow or clumsy.
• Behavior that may resemble some forms of epileptic seizures.

Narcoleptic’s are at risk for severe emotional and social dysfunction in all areas, including work, relationships and leisure activities placing narcoleptic at risk for depression and anxiety. Persons who have narcolepsy also are at risk for obesity.

The emotional, social and physical symptoms
• Depression
• Emotional Dysfunction
• Social Dysfunction
• Obesity

It is now widely accepted that narcoleptic symptoms are consequences of an auto immune disorder. Narcoleptic symptom(s), more specifically cataplexy, are said to the result of an immune attack against cells containing the brain peptide hypocretin (orexin). It is believed that the symptoms of Narcolepsy arise when the immune attack against hypocretin cells results in deficiencies in the brain peptide hypocretin. Current theory suggests that Hypocretin deficiencies could trigger chemical responses that produce the sleep attacks in patients with narcolepsy with cataplexy. Today’s research also suggests some genetic components, such as the genetic marker (HLA) DQB1-0602, are associated with the development of Narcolepsy and low levels of hypocretin. However, because up to 20% of the persons without narcolepsy also have this gene environmental trigger such as infection, trauma, hormonal changes, immune system problems, or stress are also suspected triggers.

The symptoms of narcolepsy have a propensity to begin subtly and can change dramatically over time. Although they sound dramatic the symptoms of narcolepsy are not always clinically apparent to the patient or a skilled observer. When patients do seek treatment patients often seek treatment for only one symptom such as sleep paralysis or hypnagogic hallucinations. Narcolepsy also goes undetected because it does not show up on blood test or present with any biological indicators. Partly because the patients does not report other symptoms and partly because the practitioner does not look for them symptoms of Narcolepsy can go under recognized or misdiagnosed for over 15 years. Narcolepsy can be under recognized and misdiagnosed as several other medical diagnoses such as Chronic Fatigue Syndrome, Convulsions, Epilepsy, Hypersomnia, Obstructive sleep apnea, Sleep apnea, Thyroid disorders, depression or the side effects of medications (Health Grades, 2014). In unrecognized narcolepsy with daytime hypnagogic/hypnapompic hallucinations the presentation can mistakenly incline towards delusional psychoses (Szűcs, Janszky, Holló, Migléczi and Halász, 2003). Consequently, many narcolepsy patients are diagnosed erroneously with psychiatric disorders such as depression, bi-polar, schizophrenia, or even malingering.

An incorrect diagnosis of depression, bipolar, psychosis or schizophrenia can have serious therapeutic implications for patients receiving antidepressants, mood stabilizers and anti-psychotics by exposing them to these drugs' side effects when unnecessary. In addition to this unnecessary exposure to medication side effects in many cases the narcolepsy remains undiagnosed and untreated. Undiagnosed and untreated narcolepsy can have serious consequences narcolepsy-related accidents include burns from touching hot objects, cuts from sharp objects and car accidents. The University of Maryland Medical Center (2014) reported that almost 75% of patients with narcolepsy reported falling asleep while driving, and 56% reported nearly having accidents. A few useful clinical features in differentiating narcolepsy from psychoses are: the presence of other narcoleptic symptoms, features of hallucinations and response to adequate medication (Szűcs, Janszky, Holló, Migléczi and Halász, 2003).

Exploring Psychological Theories: Freudian Theory

Perhaps Freud’s most influential piece of work in the field of psychology is his theory that divided the mind into the three fundamental components of the psyche, known as the id, the ego and of course the superego. This piece of Freud’s work asserts that the three components of the mind have to compete and opposing desires. Freud’s work argues that the ego is reality-based, the id is rather hedonistic in nature, and the superego is moral and ethical in nature.  Freud argues the development of the strong ego is necessary to keep the id and superego from disregarding reality and consequence to satisfy its own needs. These three fundamental components of the psyche are essential to understand when reviewing some of Freud’s more controversial theories.

Although his Penis Envy theory is quite controversial, Freud’s theory of Psychosexual Development is perhaps his most renowned and disputed theory (Argosy Lectures, 2014). Freud argument in his theory Psychosexual Development asserts that personality development happens through a series of childhood stages he has named oral, anal, phallic, the latent period, and the genital stage (Argosy Lectures, 2014). Freud’s theory asserts during this development period the pleasure-seeking energies of the id are concentrated on certain erogenous areas and fulfilling these needs and passing through the next stage is essential to healthy development (Argosy Lectures, 2014). Admittedly controversial and historically disputed the work of Sigmund Freud’s on psychosexual development was the first of many theories developed with a focus on understanding the phases of development contained within a human lifespan(Argosy Lectures, 2014). Because of Freud’s contribution to psychosexual development has opened the door for many new and contrasting theories to develop, regardless of its accuracy, it has further expanded our insight into human development considerably.

Life and sociocultural factors that significantly contributed to his conclusions were the era in which he was lived, the state of social affairs and human rights during this time, the social class and ethnicity in which he was born to, his own personality, personal experiences and direct social influences during his life such as his parents, two half brothers, a nephew, his wife and children (IEP, 2014). Although born in Frieberg, Moravia in 1856 by the end of 1860 Freud’s family relocated to Vienna (IEP, 2014). Consequently, it was in Vienna where he founded the first Viennese School’ of Psychoanalysis, the psychoanalysis movement and where many other subsequent developments in this field arose (IEP, 2014). Other notable influences on his work directly was Jean Charcot for his use of hypnotism and Josef Breuer for his knowledge of the healing power found in cathartic release through talking therapy (IEP, 2014).  

People disagree with the findings of Freud for a seemingly never-ending list of reasons. Many use the argument that his study methodology was unreliable and his subject sample too limited in scope, resultantly his results are unfalsifiable (Moffat, 2006). Others have indicated he discredited the evidence, even falsified and destroyed data (Moffat, 2006). Another popular argument against Freud was that his work was sexually discriminatory or bias in nature (Cherry, 2013). Donna Stewart, M.D., a professor and chair of women’s health at the University Health Network, asserted this his worked lacked inadequate insight into women’s desires. Although Freud’s view expresses a socially appropriate view for the time, his view that a women’s thoughts and actions are “dominated by their sexual reproductive functions” is a view that is largely bias, inaccurate and likely based on Freud’s own opposition to the women’s emancipation movement (Lehmann, p. 9).

Not surprisingly, despite all the controversy surrounding Freud’s works his famously coined terms “ego”, “Freudian slip” and “penis envy” as well as other theories often are still referred to in general psychology and popular culture every day (Argosy Lectures, 2014). Interestingly, there are a number of concepts that are based in Freudian theory that at first glance to not appear to have anything related to Freudian theory. This is because Freud’s work inspired many great conversations and debates that resulted in new theories and schools of thought being developed, thus expanding the scope of our understanding into human personality development and human behavior through our life span in many ways. An example of this expansion of knowledge is the behaviorism theory. Although behaviorism is a theory that seems so far way from Freudian theory it has arisen as a result of expanding ideas that are partly based on psychoanalytic assumptions about human behavior (Argosy Lectures, 2014).  

References

Cherry, K. (2013). Freud & Women: Freud's Perspective on Women. About Psychology. Retrieved from http://psychology.about.com/od/sigmundfreud/p/freud_women.htm

Lehmann, C. (2001). Women psychiatrists still battle Freud’s view of sexes. Psychiatric News, 36(14), American Psychiatric Association, p. 9.

Moffat, L. (2006). Acknowledge Freud’s Mistakes. Worker’s Liberty. Retrieved from http://www.workersliberty.org/node/6472

The Internet Encyclopedia of Philosophy. (2014) Sigmund Freud. Internet Encyclopedia of Philosophy. Retrieved from http://www.iep.utm.edu/freud/

Dissociative Identity Disorder: Why Does Misdiagnosis Occur?

The purpose of the literature review is to discuss some of the reasons offered in the current literature on Dissociative Identity Disorder that postulate why this group of patients often goes misdiagnosed or undiagnosed for several years despite seeking medical treatment for symptoms. I hypothesize that this disorder goes unrecognized because myths, media, and controversy have blinded both doctors and patients to the disorders true presenting symptomatology and that the most appropriate course of action will raise awareness and better educate the society as a whole. The reasons offered vary within the professional literature; however, common underlying themes appear to be ignorance, confusion, controversy, misconception, distortion, rejection and the hidden nature of dissociative symptoms. However, I feel the evidence congruently supports and adds to the conclusions of others, as well as to mine. The treatment for Dissociative Identity Disorder is unique and tailored to them, as such is true; one can surmise that patients with this disorder undiagnosed and untreated likely will not see any lasting improvement without an accurate diagnosis resulting in proper treatment. The evidence supports the conclusion and implies without properly educating our doctors and patients on the true presenting symptomatology we should not expect that any of these problems to dissipate or the number of undiagnosed Dissociative Identity Disorders to decrease. I believe that an accurate and speedy diagnosis will improve treatment success rates for previously low trajectory patients, and as such may be true; a collaborated effort must be made to uncover the truths, bust the myths, and educate the people on the facts about Dissociative Identity Disorder to help those struggling silently and alone.

Dissociative Identity Disorder is a mental illness in which often goes undetected for many years. This disorder manifests in childhood and becomes increasingly challenging for the patient to manage as the years go on. Often they seek treatment, are misdiagnosed and/or remain undiagnosed, and do not receive the correct treatment for many years. It is consistent throughout the literature, as well as noted by many respected experts (Boon & Draijer, 1993a; Coons, Bowman, & Milstein, 1988; Martínez-Taboas, 1991; Middleton& Butler, 1998; Putnam, Guroff, Silberman, Barban, & Post, 1986;Rivera, 1991; Ross, Norton, & Wozney, 1989), that these patients spend an average of 11.9 years in the mental health field seeking treatment for symptoms before they get an accurate diagnosis of Dissociative Identity Disorder (Chu, 2005). Many professionals would agree that many patients with Dissociative Identity Disorder are often high functioning, have jobs, maintain lives with children and families, and only the people close to them know they are suffering (Spring, 2011). Is it proposed, that these patients are so adapted to the disruptions in memory and consciousness that many of these patients only seek treatment after some crisis or build-up of stressors that leads to a sudden and shattering breakdown (Spring, 2011). Many professionals would also agree that these patients seek treatment for varying ailments and still go undetected, undiagnosed, or worse misdiagnosed for many years (Spring, 2011; Steinberg, 2008).

There are three primary tests that can be given to determine an accurate diagnosis of Dissociative Identity Disorder, including the Dissociative Experiences Scale (DES), the Somatoform Dissociation Questionnaire (SDQ-20), and the Structured Clinical Interview for Dissociative Disorders (SCID-D) (Spring, 2011). The literature supports that these diagnostic tests can accurately diagnose and differentiate a patient with a dissociative disorder from another mental illness “like schizophrenia (Fink & Golinkoff, 1990; Ross, Heber, Norton, & Anderson, 1989; Steinberg, Cicchetti, Buchanan, Rakfeldt, & Rounsaville, 1994) eating disorders (EDs; Gleaves, Eberenz, Warner, & Fine, 1995; Ross, Heber, Norton, & Anderson, 1989), panic disorder (Ross, Heber, Norton, & Anderson, 1989), borderline personality disorder (Boon & Draijer, 1993b; Fink & Golinkoff,1990), partial complex seizures (Ross, Heber, Anderson, et al., 1989), simple posttraumatic stress disorder (Dunn, Ryan,Paolo, & Miller, 1993), and dissociative disorder not otherwise specified (Ross, Anderson, et al., 1992” (…as cited by Gleaves, 1996). Given that there are so many tests available to give an accurate diagnosis, it is hard to believe many people who have Dissociative Identity Disorder will spend years seeing doctors within the mental health field only to be misdiagnosed and left untreated. Quite commonly, people with Dissociative Identity Disorder are misdiagnosed with schizophrenia, bipolar, a psychotic disorder, an affective disorder, a substance abuse disorder, borderline personality disorder, or some other personality disorder (Spring, 2011).

A misdiagnosis, in this case, can go wrong for the patient in many ways. However, my main focus of concern is medication overdose, which I myself have been subjected to at the hands of well-meaning doctors. Sometimes these patients are given powerful antipsychotic medications that they don’t need because they are misdiagnosed with schizophrenia, bipolar, or another psychotic disorder (Steinberg, 2008). Dissociative symptoms will not resolve with medications alone and need treatment that specified for this group of disorders (Steinberg, 2008). Naturally, because they are not receiving the right treatment they are still symptomatic when given medications. As a result, often these patients are overprescribed many medications in an attempt to control the symptoms.

A perfect example of how this misdiagnosis could result in further scarring the patients when a patient with Dissociative Identity Disorder is given a diagnosis of schizophrenia and given narcoleptics to treat schizophrenic symptoms.  On the mild end of the spectrum, these patients often gain weight with treatment, lose aspects of a positive self-image and/or self-esteem, and often feel stigmatized as mentally ill and/or obese. On the other end of the spectrum, there are side effects like Tardive Dyskinesia. Tardive Dyskinesia (TD) is a neurological disorder that can be a side effect of taking antipsychotic medications, like those taken to control schizophrenia (DrugWatch, 2013). Tardive Dyskinesia causes involuntary, rapid movements of the face and body (DrugWatch, 2013). Tardive Dyskinesia has no cure, symptoms may be mild or only last for a short time, but they may continue for life causing more pain and social discomfort to the patient (DrugWatch, 2013). Patients who are undiagnosed are not being treated effectively. I believe that in the long run, if people were more educated and aware of how this disorder presents more patients would be treated accurately and more successfully.

Ignorance

Ignorance or lack of information is mentioned either directly or indirectly by many others who are authorities on the subject of dissociative disorders. Author, James A. Chu (2005), confronts this question directly stating “lack of education among clinicians about dissociation, dissociative disorders, and the effects of psychological trauma…. are common reasons for the delay and/or misdiagnosis of Dissociative Identity Disorder patients (p. 73). I propose that the confusion presented by Spiegel, Loewenstein, Lewis-Ferna´ndez, Sar, Simeon, Vermetten, Carden˜a & Dell (2011), as well as, the controversies proposed by Boysen (2011), Gillig (2009), and Chu (2005) feed misconceptions and fuel controversy that lead to the rejection felt by patients and expressed by practitioners in Gillig (2009).

Confusion

It is proposed by those who seek for the revision in the diagnostic criteria that inconsistencies throughout the literature that define dissociative experiences and the inconsistencies in the diagnostic criteria has led to confusion among practitioners and mental health workers. After a careful review of the definitions of dissociation and conceptualization criteria of Dissociative Disorder in the DSM-IV-TR and the ICD-10, as well as, the conceptual issues in defining dissociation and Dissociative Disorders Spiegel, Loewenstein, Lewis-Ferna´ndez, Sar, Simeon, Vermetten, Carden˜a & Dell, (2011) advocate for a revision of the diagnostic criteria. They note that neither the DSM-IV-TR of the American Psychiatric Association (APA) nor the ICD-10 of the World Health Organization (WHO) give a consistent or clearly definitive definition for dissociation and their conceptualizations of dissociation are inconsistent (p.825). However, the censure pertaining to the inconsistencies throughout the literature that defines dissociative experiences as cause to the confusion among students, caregivers, practitioners, and professionals is not just limited to the definitions, but also to the symptomatology.

Confusion among the symptomatology, or the defined set of symptoms that are characteristic of a Dissociative Identity Disorder and exhibited by a patient, is cited by many as a leading reason for the confusion among practitioners within the mental health field. Evidence from studies demonstrates that the symptomatology in disorders like borderline personality disorder and attention deficit are very similar to the presenting symptomatology in Dissociative Identity Disorder (Gilligs, 2009). Many patients with Dissociative Identity Disorder seek treatment for affective, psychotic-like or somatic symptoms, which is likely a probable contributor to the confusion and misdiagnosis (Spring, 2011; Gilligs, 2009).

Laddis & Dell (2011) conduct an evaluation of schizophrenia and Dissociative Identity Disorder patients and find, in almost all cases of Dissociative Identity Disorder the patients report auditory hallucinations or hearing voices. However, if they report this symptom to a doctor who is not educated in dissociative disorders they will likely be misdiagnosed as having schizophrenia because this symptom is listed as part of the diagnostic criteria for schizophrenia and not for Dissociative Identity Disorder.  Along with depersonalization and derealization symptoms, a patient with Dissociative Identity Disorder will also present with many of Schneider’s (1959) rank schizophrenia symptoms just as a person with schizophrenia would. First rank symptoms, like passive influences or “somatic and mental activities that are experienced as not mine” are also found in Dissociative Identity Disorder patients,  and three studies have found that they occur more frequently in Dissociative Identity Disorder patients than in schizophrenia patients (Laddis & Dell, 2011, p. 398).  

Procedural Oversight

James A. Chu (2005), author of the “Guidelines for Treating Dissociative Identity Disorder in Adults” states “standard, diagnostic interviewing and mental status examinations do not include questions about dissociation, PTSD symptoms, or a history of psychological trauma” is another procedural oversight that leads to misdiagnosis in Dissociative Identity Disorder (p.73).  Which I believe to be the main procedural oversight that prevents an accurate diagnosis of Dissociative Identity Disorder is made sooner.  However, there is evidence within the literature to suggest that other types of procedural oversights may lead to the misdiagnosis of Dissociative Identity Disorder as well.

While I could not dispute or verify this, Sar , Warwick , & Dorahy suggests that age-related language differences create communication barriers that prevent practitioner from using the Structured Clinical Interview for Dissociative Disorders and the Dissociative Disorders Interview Schedule on children, as a result, rather than the child himself/herself being interviewed for dissociative symptoms the Child Dissociative Checklist, is administered to the child’s caregiver. I agree with Sar , Warwick , & Dorahy (2012) that if the test is not being given to the child than this is a type of procedural oversight that could create many misdiagnoses in childhood Dissociative Identity Disorder patients, which would account for the lack of case cited by a few.

Misconception

In the literary critique by Sar , Warwick , & Dorahy, (2012), the authors confront some of the unwarranted conclusion in the Boysen (2011) “The scientific status of childhood Dissociative Identity Disorder” (Psychotherapy and Psychosomatics, 2011, p. 329-34). In the response to Boysen’s (2011), Sar , Warwick , & Dorahy (2012) conclude their critique, declaring more research is needed to make age-appropriate clinical evaluation tests for children and suggests “screening studies on children and adolescents in the community” before anyone could consider childhood Dissociative Identity Disorder an extremely rare phenomenon  as Boysen states (p.2).  Throughout the literature, many note a common miscomputation of Dissociative Identity Disorder is that it is rare, even though there is mounting evidence to suggest that it is fairly common. The current research indicates a prevalence of 1-3 % of the population could have a dissociative disorder (Spring, 2011; Chu, 2005).

Controversy

Despite misleading conclusions that may have been drawn by Boysen, (2011) he directly addresses the controversial nature of a Dissociative Identity Disorder, which I believe is at the heart of many misconceptions about Dissociative Identity Disorder diagnosis and may lead to many misdiagnoses. It was proposed, that the limited amount of relevant research into childhood cases of Dissociative Identity Disorder and the conflicting models of etiology are the reasons behind the ongoing controversy of this diagnosis. Boysen (2011) and Gillig (2009) both allude that the controversy surrounding the etiology of the disorder asks: is this disorder willful and malingering and/or iatrogenically caused symptoms as Spano’s (1994) Sociocognitive Model proposed or is it as leading evidence suggests, a disorder with a trauma etiology?

There are plenty of advocates for the Trauma Model (TM), which describes an etiology of severe childhood abuse, however, this model, as well as the Sociocognitive Model (SM), has been the subject of intense analysis by skeptics.  The Sociocognitive model first proposed by Spano’s (1994) proposed that Dissociative Identity Disorder was iatrogenically created and maintained by therapists, and suggests that individuals affected are enacting a social role. This suggestion has been supported openly within the literature only by a few. However, there seems to be more evidence or studies that support the trauma model of Dissociative Identity Disorder.

Boysen (2011) argues, another area of controversy among clinicians is the lack of evidence or data that discusses the status of Dissociative Identity Disorder among children, and it is often-a repeated problem with the diagnosis that childhood cases are rare. Boysen’s (2011) literary research produced a total of 255 cases of childhood Dissociative Identity Disorder, which I feel is evidence enough that childhood Dissociative Identity Disorder exists to warrant this being considered a real diagnosis. Within this sample, 93% were children who were in treatment, and only 23% of the case studies were multiple personalities the presenting problems. This alludes to the conclusion, that the majority of the time the presenting symptom in children will not be multiple personalities and further evaluation will be needed to accurately diagnose a child patient with Dissociative Identity Disorder.  In fact, research indicates that only 6 % of the people with Dissociative Identity Disorder will present publicly and obviously with ‘multiple’ or ‘dissociated’ identities (Kluft…as cited by Spring, 2011).

Boysen also states 65% of the research for all 255 cases was done by only four U.S. research groups. The author perhaps oversteps the bounds of his evidence and concludes “childhood Dissociative Identity Disorder itself appears to be an extremely rare phenomenon that few researchers have studied in-depth” which I find to be a misleading conclusion at best. If only a few researchers are looking into this pressing matter than naturally, it would likely be an extremely rare phenomenon to find relevant research on this matter too. I feel this conclusion is suggestive of something misleading because there are research articles that evaluate children and have demonstrated dissociative symptomatology in children including populations of children and adolescents with other disorders such as Post-Traumatic Stress Disorder (PTSD; Putnam, Hornstein, & Peterson, 1996), Obsessive-Compulsive Disorder (OCD; Stien & Waters, 1999) and reactive attachment disorder, as well as in general populations of traumatized and hospitalized adolescents (Sanders & Giolas, 1991; Atlas, Weissman, & Liebowitz, 1997) and delinquent adolescents (Carrion & Steiner, 2000) (…as cited by the International Society for the Study of Trauma and Dissociation, 2013). I feel unwarranted conclusions like this one contribute to current misconceptions and controversies that keep many children and adults with Dissociative Identity Disorder undiagnosed and untreated. Many professionals have suggested people perceive this disorder as a rare, however as the research revealed this disorder is much more common than once believed (Chu , 2005; Spring, 2011).

Recently, Boysen was published again, this time with VanBergen (2013) to which they review the published research (2000-2010) on adult Dissociative Identity Disorder in an attempt to review the scientific and etiological status of Dissociative Identity Disorder within the community. Their review of the research found 1171 new cases of Dissociative Identity Disorder reported. The discern that Dissociative Identity Disorder is a topic of study remains ongoing but lacks the research to prove or disprove controversy surrounding it ecology, but overall is accepted within the scientific community (Boysen & VanBergen, 2013).     

Rejection

It was proposed in the literature that doctors refuse to accept this condition as a real diagnosis. Carolyn Spring is a former social worker who specialized in working with traumatized children and is the current manager for Partners of Dissociative Survivors (PDAS) and Trauma and Abuse Support Centre (TASC). In 2011, the “Healthcare Counseling & Psychotherapy Journal” published Spring’s article “A Guide to Working with Dissociative Identity Disorder”, in which she openly speculates that the majority of people will receive a misdiagnosis because doctors refuse to accept this condition as a real diagnosis. Sping’s (2011) conclusions are confirmed in Gleaves (1996, p. 46) who presents a patient statement from Cohen et al (1991) where a patient reports being rejected by a doctor, met by skepticism, and suspected of attention-seeking behavior.

Distortion

Reflecting on Spring’s whole article, she also names a second culprit in her opening line, “The view of many people with regard to Dissociative Identity Disorder (DID) has been influenced by Hollywood representations such as in the book and film Sybil” (Spring, 2011, p.1 ). Spring (2011) addressed the nature of dissociative symptoms and speaks about Sybil, media, and misconception. Spring presents the diagnostic criteria given, the presenting symptoms, and leaves the reader to compare this to the media portrayed Sybil.  Spring (2011) makes it very clear, the Hollywood portrayed “Sybil's" dramatized presentation of Multiple Personality Disorder has given people a false image of how Dissociative Identity Disorder presents. In truth this disorder does not often present so plainly as the movie portrays. Spring’s whole argument seems to allude that she believes two causes are at the heart of misdiagnoses in Dissociative Identity Disorders- misinformed doctors that believe this disorder does not “exist” and/or that the media has corrupted our minds with a false image of how the disorder presents in such a way that the disorder is not recognized for what it is when it presents. I agree the famous book and film “Sybil” has given a false interpretation of what this disorder presents as and the media continues to feed this distortion of the truth with shows like “United States of Tara”.  I agree with Spring (2011), who suggests that the false vision the media portrays causes confusion among society. 

Concealed Nature of Dissociative Symptoms 

In truth, the symptoms of Dissociative Identity Disorder are hidden, which is notably contrary to what the media picture presents and does create confusion that could lead to misdiagnosis (Chu, 2005). Steinberg (2008) argues the symptoms of Dissociative Identity Disorder are often hidden even from the patient, suffering is evident it, but is often hard to describe, often presenting with co-morbid diagnosis’s and/or symptoms such as depression, anxiety, or substance abuse. Therefore, it takes a skilled doctor with an accurate diagnostics test, like the SCID-D, to detect and diagnose dissociative disorders. Elizabeth Howell describes Dissociative Identity Disorder as ‘a disorder of hiddenness’, and proposed that the majority of people with Dissociative Identity Disorder are motivated by shame to conceal their symptoms (as cited by Spring, 2011). However, I propose that shame and fear of rejection and stigmatization prevent patients from coming forward as well.

                  According to Steinberg, the five obvious and hidden symptoms of Dissociative Disorders are “Amnesia or memory problems involving difficulty recalling personal information; depersonalization or a sense of detachment or disconnection from one’s self or feeling like a stranger to one’s self; derealization or a sense of disconnection from familiar people or one’s surroundings; identity confusion or inner struggle about one’s sense of self/identity; identity alteration or a sense of acting like a different person”. Along with these symptoms these patients usually present with comorbid disorders like anxiety, depression and mood swings that make the other symptoms hard to see or may in some cases mask symptoms almost completely. 

True presentation of Dissociative Identity Disorder.

It has been recommended by some professionals that “a set of polythetic criteria would more accurately portray the typical polysymptomatic presentations of Dissociative Identity Disorder patients” (Dell, 2001… as cited by Chu, 2005). So I composed a symptom complex based on the literature reviewed that will help us identify a patient with Dissociative Identity Disorder in the future.  I feel this may be the best way to educate the people and clear some of the confusion among society as a whole.  A symptom complex is defined by Merriam and Webster (2013) as a group of symptoms that occur together and are characteristic of a certain disease, disorder, or condition.

Research from many professionals and conducted studies (Boon & Draijer, 1993b; Coons, Bowman, & Milstein, 1988; Putnam, Guroff, Silberman, Barban, & Post, 1986; Ross et al., 1990; Ross, Norton, & Wozney, 1989; Schultz, Braun, & Kluft, 1989) have collectively documented a relatively clear set of clinical Dissociative Identity Disorder features.  A clear set of clinical Dissociative Identity Disorder features “will include dissociative symptoms such as amnesia, ongoing amnesia and lack of autobiographical memory for childhood, chronic depersonalization and derealization, as well Schneiderian symptoms or hearing voices and passive influence experiences, and identity alteration…” (…as cited by Gleaves, 1996). To further clarify, derealization refers to distortions in perceptions of objects, events, or one’s surroundings (Carlson, E. B., Dalenberg, C., & McDade-Montez, E. (2012), while depersonalization is often accompanied by derealization, derealization refers to a disconnection from oneself.

            Presumably, a person with amnesia will likely not be aware of the amnesia because they are unaware of the event, as well as, a person with depersonalization, derealization, or Schneiderian Symptoms unless directly asked and educated about these symptoms would likely not know that these symptoms are not present in every one or are suggestive of a mental illness. This implies as the evidence suggested previously states, a person with symptoms of Dissociative Identity Disorder will likely be unaware that these are symptoms’ of a mental disorder, they may have a hard time describing them, or may never mention them because they perceive them as normal. Therefore, I feel it is important for clinicians to be screening for them.

Patients with dissociative disorders suffer from a disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment (Spring, 2011; Steinberg; and Psychotherapy and Counseling, 2013; American Psychiatric Association, 2000a, p. 519; Chu, 2005, p. 74). This lack of a coherent sense of autobiography itself is what leads to problems associated with establishing a core sense of identity (Spring, 2011). However, since they have lived most if not all of their lives with this problem many have learned creative coping mechanisms that help them cover these symptoms. Patients may find that memories and feelings may not go together, there may be recalled information without the accompanying affect, or there may be overwhelming feelings with no conscious memory of their cause (Spring, 2011).

These patients often mistaken refer to themselves as “we” instead “I”, or refer to themselves as having, among others “parts,” “parts inside,” “aspects,” “facets,” “ways of being,” “voices,”“multiples,” “selves,” “ages of me,” “people,” “persons,” “individuals,” “spirits,” “demons,” “lines,” and “others” (Chu, 2005, p. 74). These patients may attempt to describe periods of depersonalization or articulate hearing voices (Gillig, 2009; Psychotherapy and Counseling (2013) proposed that these patients are usually vulnerable to suggestive influences and highly hypnotizable. They may manifest posttraumatic symptoms such as nightmares, flashbacks and startle responses, or also PTSD like symptoms and/or they may self mutilate, possess the ability to control pain or experience conversion symptoms (e.g. pseudoseizures) (Psychotherapy and Counseling, 2013). In some studies, a pattern of child abuse or a “disorganized and disoriented attachment style in the absence of social and familial support” seems to be evident in these patients’ family histories. Other studies present, the parenting style these patients are subjected to, as authoritarian and rigid, but strangely enough with reverse order of the parent-child relationship (Gillig, 2009).

Instead of presenting obliviously histrionic or unstable as portrayed in the media, these patients will present with co-morbid disorders both dissociative and post-traumatic symptoms, as well as many apparently non-trauma-related issues such as depression, substance abuse, eating disorders and anxiety (Spring, 2011) Evidence from a study conducted by Armstrong and Loewenstein (1990) administered a variety of objective and projective testing instruments to group of 14 patients with Dissociative Identity Disorder to access the presenting personality profiles of patients with Dissociative Identity Disorder. This study found that persons with Dissociative Identity Disorder were not histrionic or unstable, but rather were intellectualized, obsessive, and introversive (Gleaves, 1996).

Fink and Golinkoff (1990) conducted a study which evaluated persons with Dissociative Identity Disorder, as well as a sample of patients with borderline personality disorder or schizophrenia and found the average Histrionic scale of the MCMI was only 46.3 for the dissociative identity disorder group and patients scored highest on the Avoidant scale with 102.9 percent, followed by 97.3 percent with Self-Defeating personality styles. This suggests that persons affected will likely not appear in an overdramatized histrionic presentation instead the person will likely be intellectualized, obsessive, introversive, with an avoidant and/or self-defeating personality profile.

Gillig (2009) presents a typical presenting person with Dissociative Identity Disorder may be a 30-year-old woman with a history of chronic suicidal feelings and/or some suicide attempts. The patient may report a history of childhood abuse, typically the patients report a higher occurrence of sexual abuse than the incidences of physical abuse. Patients may report sexual promiscuity, decreased libido and inability to have an orgasm. They may dress in clothes typical of another gender and/or claim to be another gender. The high levels of dissociative experiences experienced by these patients may also include many somatic symptoms (e.g. Briquet syndrome or somatization disorder). These patients also may report meeting people who say they are acquainted with them, but whom they do not recall meeting, and/or find clothes within their own possessions that they do not recall purchasing and normally would not wear.

Discussion 

In this review, we sought to answer the question of why these patients go undiagnosed and misdiagnosed for so many years. While reviewing the current literature available to the public and students we ask what are the reasons offered in the literature on Dissociative Identity Disorder that explain why this group of patients often goes misdiagnosed or undiagnosed for several years, despite seeking medical treatment for symptoms? We attempt to understand the proposed challenges associated with diagnosing these patients, as well as, aim to educate, inform and shed light on misconnections by presenting the truth in light of the evidence from current literature.

Thus far, in all of my life, I have not seen one magazine or handout at the doctor’s office, nor at the psycho therapist’s office, the psychologist’s office, or anywhere for that matter, that provides the world with accurate information on Dissociative Identity Disorder’s true presenting symptoms. Therefore, I presume the only information known to the general public is that which the media portrays- the exceptions being those who intentionally look for the correct answers from reputable sources on the topic, like me. While Dissociative Identity Disorder looks comical in shows like “United States of Tara”, and dramatic and alluring on “One Life to Live” it is generally appears nothing like these shows portray and these patients are often suffering silently.

We find that the literature supports the conclusion that this disorder goes unrecognized because myths, media, and controversy have blinded both doctors and patients to the disorder's true presenting symptomatology. If this is true than the most appropriate course of action will be to invest time into carefully conducting research that will raise awareness and better educate society as a whole.

Method

We conducted a brief interview of four psychiatric patients who have had little success with their current diagnosis, have tried medications to treat symptoms, and have at least one hidden symptom undiagnosed and untreated. We expected to find that these patients have never been interviewed by a doctor about dissociative symptoms, nor been educated about the hidden symptoms. We expected to find that these patients have all been subjected to trial and error medication treatment before settling on current treatment. We expect to find that all patients will report at least one side effect of mediations and a low level of satisfaction with treatment. We hope to briefly illustrate that there is some truth to the conclusions and assumptions drawn in this review. We hope to demonstrate and inspire more research of this nature to truly evaluate the number of undiagnosed untreated dissociative patients and the impact of misdiagnosis on dissociative patient’s success rates.  

Participants

Participants, three females, and one male had all previously been diagnosed with a mental illness, treated with medications and/or therapy. Participants were chosen based on their low success rate with current diagnosis and/or treatment. Participants selected have reported at least one childhood trauma, and have at least one primary symptom, such as amnesia, or periods of life, events or time that are missing from memory. Participants were informed that this was a study for school and interviewed individually with the DES online screening tool and the questioner designed for the study. 

Procedures

The method of study was first by the internet and then interview, using the search engines Google Scholar and Google, as well as the Argosy Online Library Database. We used keywords like “Dissociative Identity Disorder, and Dissociative Identity Disorder and Misdiagnosis” to search for related text. Using this method there were no actual studies that pertained to my question exactly, however, within the literature, there were plenty of different suggested reasons that misdiagnosis occurs among this group of patients. An experimental questioner was then made to determine age, diagnosis, years in treatment, a number of medications tried to treat symptoms, levels of satisfaction and success on current medications, side effects experienced, knowledge of Dissociative Identity Disorder, and if they were previously screened for Dissociative Identity Disorder.

We interviewed and tested four participants using the DES as a screening tool to ask about symptoms of dissociation. Overall the DES, has been found to have good reliability and validity, ranging from approximately .80 to .96 (Bernstein & Putnam, 1986; Frischolz et al., 1990), and internal consistency has repeatedly been found to exceed.90 (Frischolz etal., 1990; Cleaves et al., 1995) (Ross Institute, 2007). Additionally, the DES has been demonstrated as a good screening tool, as it can differentiate  or single out a Dissociative Identity Disorder diagnoses with a sensitivity of .93 and a specificity of .86 when administered along with instruments measuring similar and different constructs (Gleaves & Eberenz, 1995a; Boon and Draijer, 1993) (Ross Institute, 2007). The higher the DES score, the more probable it is that the person has Dissociative Identity Disorder. This is a screening tool that alone does not constitute a diagnostic tool, but can be used to discern if a clinical assessment for dissociation is warranted.

The Expectation of Study

We expected to find patients with low satisfaction in treatment success rates and higher than normal levels of dissociative symptoms.

DES Results

The average test result on the DES was 54.25, which is well beyond the 30-40 that is suggested as a positive marker for dissociative symptoms’ and Dissociative Identity Disorder. The average patient with Dissociative Identity Disorder scores 40 or higher, with roughly 17% of patients with Dissociative Identity Disorder scoring lower than a 20 (Ross Institute, 2007).

Treatment

The average age of participants was 37 years old, with an average of 7.4 years seeking treatment. One patient reports a diagnosis of Depression, three patients report a diagnosis of bipolar, and one patient reports a co-morbid diagnosis of post-traumatic stress disorder. The average amount of medications tried before settling on current medication to treat for symptoms was 5 different types of medication. Each participant was prescribed an anti-psychotic at least once during their treatment with no real success noted. The average amount of medications taken daily to treat symptoms was 2.5 pills.

Satisfaction with Treatment

Using a 1-10, 1 being not satisfied with success and ten being very satisfied with the treatment, self-rated measures of satisfaction with the success of treatment was reported by the patient was an average of 3. Patents report a reduction in only a very few symptoms that can be treated successfully with mediations, like insomnia with tranquilizers and reduction of anxiety with benzodiazepines. 

Side effects

Each patient reported considerable weight gain as a side effect associated with medication treatment, with an average weight gain was about 54 lbs. Three patients report other side effects like shakes and tremors, while two of four patients report symptoms of Tardive Dyskinesia. Each person reports a lower self-image or self-esteem as a result of stigmatizing related to either the disorder or side effects of treatment (e,g weight gain.).

Knowledge of Dissociative Identity Disorder

Participants reported that they have never seen literature on Dissociative Identity Disorder in the doctor’s office, as well as, each person reports seeing at least one dramatized representation of Dissociative Identity Disorder on television.  Each patient reports that they have never been asked about and/or spoken with by any doctor about dissociative symptoms.

Discussion

We expected to find patients with low satisfaction in treatment success rates and higher than normal levels of dissociative symptoms. We expected to see this result because we were specifically looking for them based on the presenting symptom complex found in the literature. We sought to find these people only to briefly demonstrate the validity of the conclusions and assumptions drawn from the literature. This was to hopefully demonstrate not only how easy it is to screen for a referral, but that many people are unaware of their dissociative symptoms and have not been screened before.

In light of the fact, that I am an undergraduate student with limited time and resources to complete this study, we note that this literary review was with limited access to all literature available at the time of this review. The study was also done with a limited amount of participants that were selected based on current diagnosis, success rates, and how well they fit proposed presenting symptom complex of someone who has an undiagnosed dissociative disorder. A total of only 4 participants, one man, and three women were interviewed using the DES and an experimental questioner to briefly access the accuracy of some of the conclusions made in this paper. While this selection of participants  may appear bias, this study serves the purpose of briefly demonstrating that patients are unaware of the true presentation of dissociative symptoms, patients have been diagnosed or treated for a mental illness and have not been evaluated for a dissociative disorder (e.g. they have not been interviewed, questioned, or treated for these dissociative symptoms), these patients may have an undiagnosed dissociative disorder, these patients have sought treatment for a number of years, they are or have been receiving medications that cause the side effects, and are unsatisfied with treatment results - which were all conclusions drawn from the review of literature.

We hope to demonstrate a need for further study to evaluate the impact of misdiagnosis, medication treatment and success rates among this group of patients and advocate for educators, care providers, patients and society to be better educated on the true presenting symptom complex of Dissociative Identity Disorder. We believe the evidence supports the conclusions drawn from the literature, there are patients in treatment for other mental disorder that has not been interviewed or evaluated for dissociative symptoms, yet clearly have untreated dissociative symptoms present and low success rates on medication treatment. Since patients treated for dissociative identity symptoms often see a reduction in symptoms with treatment and dissociative symptoms will not be alleviated by medications treatment alone (Steinberg, get date), it is reasonable to presume that patients with undiagnosed Dissociative Identity Disorder who are not receiving treatment or who are receiving the wrong treatment will not see a reduction of symptoms.

The symptoms of Dissociative Identity Disorder are often hidden even from the patient, suffering is evident, but it's hard to articulate into words and often presents with a co-morbid diagnosis and/or symptoms such as depression, anxiety, or substance abuse. Therefore, skilled doctors and an accurate diagnostics test, like the SCID-D, are needed to accurately diagnose a dissociative disorder. While these things may be true, it is also true that anyone who is keenly alert and educated in dissociative disorders can easily give any other person who is suffering silently a DES screening and a referral to a doctor.

While more research is needed to determine the true impact of misdiagnoses in this group of patients, the study clearly demonstrates that this unexplored area needs to be evaluated more thoroughly with the intent of improving the diagnostic criteria, clinician and patient awareness, and improving patient treatment success rates. Raising awareness in society about misconceptions portrayed by media, presenting the public with the true image of Dissociative Identity Disorder, will likely increase the number of patients reporting dissociative experiences. For those who worry about fake or malingering cases of Dissociative Identity Disorder, one should note, our current diagnostic tools, like the SCID-D, can accurately evaluate and diagnose a person with Dissociative Identity Disorder or other dissociative disorders and other mental illnesses. However, this is only true if the person is evaluated for these hidden symptoms, which are routinely not asked about on other mental health questioners.

It is important to make sure that if we are the authority on the subject, as in, we are the doctor or we are a care provider, that we are providing the care that will best suit the patient; this includes an accurate diagnosis and the right treatment for Dissociative Identity Disorder when needed. Revisions to admittance tests and clinical procedures would likely give way to many of these patients being treated sooner. As caregivers, it is our duty to maintain our education on matters so pressing as one’s mental health, giving patient’s antipsychotic medication should not be done so lightly or without further evaluation, as there are many possible side effects associated with these medications that could further scar these already fragile minds.

As Dissociative Identity Disorder has been the subject of review for almost 200 years, I think it is time that we start to evaluate our patients for this disorder more thoroughly, accepting that despite its unknown origin and surrounding controversy many patients are suffering from symptoms and need treatment. I feel given the evidence presented within the literature, there is clearly a need within the mental health field for improved diagnostic criteria and procedure. I can only hope that my review clearly presents why higher levels of awareness about Dissociative Identity Disorder is needed among society as a whole, but especially the doctors and clinicians.

References

Boysen, G, A. (2011). The Scientific Status of Childhood Dissociative Identity Disorder: A Review of Published Research. Psychotherapy and Psychosomatics, 80(6), 329-34. doi: http://dx.doi.org/10.1159/000323403

Boysen, G. A., PhD., & VanBergen, A. (2013). A review of published research on adult Dissociative Identity Disorder: 2000-2010. Journal of Nervous and Mental Disease, 201(1), 5. Retrieved from http://search.proquest.com/docview/1268431150?accountid=34899

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