Dissociative Identity Disorder,
formerly called Multiple Personality Disorder is a disorder in which the persons suffers from a disturbance in normal integrative functions of memory,
identity, and consciousness. The DSM-IV-TR (2012) has classified Dissociative
Identity Disorder under the following criteria: “The presence of two or more
distinct identities or personality states that recurrently take control of the
person’s behavior, each with its own relatively enduring pattern of perceiving,
relating to, and thinking about the environment and self with an inability to
recall important personal information that is too extensive to be explained by
ordinary forgetfulness” (American Psychological Association, 2012, Butcher,
2009, p.292). This disturbance is “not caused by physiological effects of a
substance like blackouts or chaotic behavior during Alcohol Intoxication or a
general medical condition like complex partial seizures” (American
Psychological Association, 2012; Butcher, 2009, p. 2009). Lastly, in children,
these “symptoms are not attributable to imaginary playmates or other fantasy
play” (American Psychological Association, 2012).
Current research of Dissociative
Identity Disorder has focused on understanding the memory disturbances,
clinical features, best treatment and as always proving the etiological
validity of the diagnosis. The etiological validity of the diagnosis has been
of particular interest to researchers because this diagnosis has historically
been discounted as not-real because of a controversy surrounding its pathology.
Spano’s (1994) suggested the sociocognitive model of Dissociative Identity
Disorder, that suggested this disorder is constructed iatrogenically through
therapists and maintained by clients who enact social roles. However, most, if
not all, of the current research, discredits the sociocognitive model of
Dissociative Identity Disorder and supports the trauma models which suggests
that development of did nearly always occurs in the face of early trauma and
childhood abuse (International Society for the Study of Trauma and
Dissociation, 2011). In fact, the data supports the validity of three
different trauma models.
The Four Factor Model
The Four Factor Model suggests
that the following for factors precede the development of Dissociative Identity
Disorder: the child has the capacity for dissociation, the experiences that
overwhelm the child’s non-dissociative coping capacity, there is secondary
structuring of Dissociative Identity Disorder in which alternate
identities with individualized characteristics such as names, ages, genders;
and there is a lack of soothing and restorative experiences rendering the child
isolated or abandoned and need to create ways of managing distress on their own
(International Society for the Study of Trauma and Dissociation, 2011).
Structural Dissociation Model
The Structural Dissociation Model
of development in Dissociative Identity Disorder supports that this disorder
develops as a result of the failure to integrate aspects of personality,
including ideas and functions, following traumatizing events. In this model,
the whole personality system is first divided into two parts including the
“apparently normal part of the personality” dedicated to daily functioning and
an “emotional part of the personality” dedicated to defense i.e
psychobiological functions of survival in response to life threat, such as
fight/flight (International Society for the Study of Trauma and Dissociation,
2011). This theory suggests that chronic traumatization, neglect, and/or child
abuse can lead to “secondary structural dissociation and the emergence of
additional emotional parts of the personality” (International Society for the
Study of Trauma and Dissociation, 2011).
Developmental Model
In the Developmental Model of
Dissociative Identity Disorder, this disorder is thought to begin in childhood
when early attachment needs are not met, childhood integration does not occur
and personalities states do not integrate into one continuously unified
personality state (International Society for the Study of Trauma and
Dissociation, 2011). Attachment to primary caregivers is a biologically
programmed need and attachment style is an important factor in childhood
development and the development of relationships later in life (Howell, 2011, p.89-104).
Healthy attachment occurs when the primary caregiver and the child form a
secure bond. A secure bond is formed when the caregiver responds to the babies
needs in a way that soothes him or her and keeps the baby happy and safe, thus
the baby develops a feeling that their caregiver is a secure base which they
can leave to explore and then return to when distressed (Howell, 2011,
p.89-104). However, when the child forms a bond because this caregiver is the only source of the attachment and the relationship must be preserved, even in
the face of abuse, a disorganized attachment is often the result (Howell, 2011,
p.89-104).
No one is born with a unified
sense of self or personality this is created through linking behavioral and
personality states (Simeon, 2008). A sense of a unified identity develops from
experience in childhood when behavior states become linked over time and
grouped together in sequences that flow effortlessly (Howell, 2011). For proper
integration and identity development, this linking of behavioral and
personality states must occur (Howell, 2011). For this linking to occur, the
child must have a secure attachment that responds to the child in such a way
that the child begins to create an internal singular representation of themselves
(Howell, 2011). In the face of severe ongoing trauma and neglect which is
repeated consistently throughout early childhood and other important
developmental stages integration or the development of a unified sense of
identity is delayed (Howell, 2011).
A child has the natural ability
to separate many of their feelings and memories from consciousness (Howell,
2011). This innate ability allows children in the face of abuse to escape to a the fantasy world and create alternate states (Howell, 2011). In the face of
ongoing neglect and trauma, these alternate states can endure the abuse or
neglect while the child maintains attachment. Sadly, if this pattern of abuse
and attachment continues through development these dissociated parts (most
commonly referred to as alters) can develop a sense of self, accompanied by
their own memories, state of consciousness, biophysical characteristics, and
manifest their own speech mannerisms, physical behavior, handwriting, somatic
manifestations of the disease, sense of body, sense of history (Howell, 2013).
Commonly terminology to describe alters includes describing them by their
function or characteristic, i.e. hosts, children alter, abuser alters,
differently gendered alters, animal alters, manager alters, inner-self helpers,
protector alter, caretakers alters and abuser alters (Howell, 2011).
Dissociative states are a normal
response to trauma and stress found in all humans across all cultures and
studies indicate that the etiology models of DID that explain the symptom
patterns found in Dissociative Identity Disorder patient that include chronic
childhood trauma have validity for the entire human race (Ross & Ness,
2010). Dissociative Identity Disorder differs from simple dissociative states
because the dissociated states develop a sense of self and identity and there
are dissociative barriers or an amnesic boundary between the fragmented states
of self-called alters (Dissociative Identity Disorder, 2013). Interestingly,
research demonstrates these different alters show variable “visual acuity,
medication responses, allergies, plasma glucose levels in diabetic patients,
heart rate, blood pressure readings, galvanic skin response, muscle tension,
laterality, immune function, electroencephalography and evoked potential
patterns, functional magnetic resonance imaging activation, and brain
activation and regional blood flow using single-photon emission computed
tomography and positron emission tomography with switches” (International
Society for the Study of Trauma and Dissociation, 2011, p. 121).
While this sounds as though it
may appear dramatic in easy to spot this actually contrary to the truth, in
fact, less than 6% of the population with Dissociative Identity Disorder
will present so obviously (International Society for the Study of Trauma and
Dissociation, 2011). More likely they will not appear in and the overdramatized histrionic presentation that is often presented in the media,
instead, the person will likely be “intellectualized, obsessive, introversive,
with an avoidant and/or self-defeating personality profile 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” (Jewels, 2013). The symptoms displayed can be
categorized more accurately in three major groups’ straight forward
dissociative symptoms, Schneiderian first-rank symptoms, and psychotic-like
dissociative symptoms (Dell, 2006). Straight forward dissociative symptoms
include “amnesia, voices, conversion, self alteration, derealization,
depersonalization, flashbacks, trances, identity confusion and awareness of
alters” (Dell, 2006). Schneiderian first-rank symptoms include “voices arguing,
voices commenting, thought withdrawal, thought insertion, made impulses, made
feelings and made actions” (Dell, 2006). Lastly, Psychotic-like dissociative
symptoms including both “auditory hallucinations and visual hallucinations” are
also commonly reported by these patients (Dell, 2006).
Tragically, the classification of
the DSM-IV-TR barely touches many of the important factors associated with
making a diagnosis of Dissociative Identity Disorder such as causation and
etiology, terminology, functional dynamics, symptomatology and most importantly
non-observable symptoms such as state-dependent amnesia, conversion symptoms,
self-alteration, derealization, depersonalization, flashbacks, trances,
identity confusion, awareness of alters, voices, thought withdrawal and
insertion, made impulses, feelings and actions and nonpsychotic auditory and
visual hallucinations (Dell, 2006). Accurate diagnosis of this disorder can be
done with diagnostic tools such as the Dissociative Experiences Scale (DES), the
Somatoform Dissociation Questionnaire (SDQ-20), and the Structured Clinical
Interview for Dissociative Disorders (SCID-D), as well as, through patient
self-reports and clinician observation (International Society for the Study of
Trauma and Dissociation, 2011). Sadly, despite diagnostic availability often
these patients spend 11.9 years seeking treatment before they receive an
accurate diagnosis (International Society for the Study of Trauma and
Dissociation, 2011). Misdiagnosis for a Dissociative Identity Patient really is
tragic because treatment can significantly reduce symptoms and with integration
therapy helps the patient form a more unified and functioning sense of self.
Treatment that is given with a
focus on relieving dissociative symptoms is effective in reducing a range of
symptoms associated with dissociative disorders including dissociation,
depression, posttraumatic stress disorder, distress, and suicidality (Brand,
Classen, McNary & Zaveri, 2009). Effective therapy for these patients
often includes phase-oriented treatment plans starting with phase one establishing
safety, stabilization, and symptom reduction (International Society for the
Study of Trauma and Dissociation, 2011, p.135). The focus of early treatment is
helping the patient understand, accept, and access the alternate identities
that play an active role in their current lives will help the patient develop
internal cooperation and increase co-consciousness (International Society for
the Study of Trauma and Dissociation, 2011, p.139). In phase two, the
therapeutic focus is on confronting, working through, and integrating traumatic
memories (International Society for the Study of Trauma and Dissociation, 2011,
p.135) The later stages of therapy are focused on identity integration and
rehabilitation (International Society for the Study of Trauma and Dissociation,
2011, p.135).
Dissociative identity disorder
has been closely linked to early childhood abuse, trauma memories and
disorganized attachment patterns that delay the normal process of normal
personality development and memory integration in early childhood. Dissociative
Identity Disorder is a challenging mental health disorder to recognize and
treat because of multiple causative factors and confusing symptomatology. It is
important for those who are working in the field to be aware of the etiology of
Dissociative Identity Disorder, the symptoms and presenting a presentation,
current diagnostic tools, terminology, and treatment for this disorder because
this disorder is often misdiagnosed or left undiagnosed and untreated.
Treatment of this disorder mainly consists of psychotherapy geared at relieving
dissociative symptoms and the integration of dissociated memories and
personality states. This treatment is unique to this group of patients and
medication alone will not relieve the dissociative symptoms, which is why an
accurate diagnosis is vital to symptom reduction and treatment.
.
References
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