Dissociative Identity Disorder

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Dissociative identity disorder (formerly called Multiple Personality Disorder or MPD) is defined in the DSM-IV-TR as the presence of two or more personality states or distinct identities that repeatedly take control of one’s behavior. The patient has an inability to recall personal information. The extent of this lack of recall is too great to be explained by normal forgetfulness. The disorder cannot be due to the direct physical effects of a general medical condition or substance.[1]

DID entails a failure to integrate certain aspects of memory, consciousness and identity. Patients experience frequent gaps in their memory for their personal history, past and present. Patients with DID report having severe physical and sexual abuse, especially during childhood. The reports of patients with DID are often validated by objective evidence.[1]

Physical evidence may include variations in physiological functions in different identity states, including differences in vision, levels of pain tolerance, symptoms of asthma, the response of blood glucose to insulin and sensitivity to allergens. Other physical findings may include scars from physical abuse or self-inflicted injuries, headaches or migraines, asthma and irritable bowel syndrome.[1]

DID is found in a variety of cultures around the world. It is diagnosed three to nine times more often in adult females than males. Females average 15 or more identities, males eight identities. The sharp rise in the reported cases of DID in the U.S. may be due the greater awareness of DID’s diagnosis, which has caused an increased identification of those that were previously undiagnosed.[1]

The average time period from DID’s first presentation of symptoms to its diagnosis is six to seven years. DID may become less manifest as patients reach past their late 40’s, but it can reemerge during stress, trauma or substance abuse. It is suggested in several studies that DID is more likely to occur with first-degree biological relatives of people that already have DID, than in the regular population.[1]

Contents

Symptomatology

Individuals diagnosed with DID demonstrate a variety of symptoms with wide fluctuations across time; functioning can vary from severe impairment in daily functioning to normal or high abilities.[2]

Patients may experience an extremely broad array of other symptoms that resemble epilepsy, schizophrenia, anxiety disorders, mood disorders, post traumatic stress disorder, personality disorders, and eating disorders.[2]

Causes

The causes of dissociative identity disorder are theoretically linked with the interaction of overwhelming stress, traumatic antecedents,[3] insufficient childhood nurturing, and an innate ability to dissociate memories or experiences from consciousness.[2] Prolonged child abuse is frequently a factor, with a very high percentage of patients reporting documented abuse[4] often confirmed by objective evidence.[1] The Diagnostic and Statistical Manual of Mental Disorders states that patients with DID often report having a history of severe physical and sexual abuse. The reports of patients suffering from DID are "often confirmed by objective evidence," and the DSM notes that the abusers in those situations may be inclined to "deny or distort” these acts.[1] Research has consistently shown that DID is characterized by reports of extensive childhood trauma, usually child abuse.[5][6][7] Dissociation is recognized as a symptomatic presentation in response to psychological trauma, extreme emotional stress, and in association with emotional dysregulation and borderline personality disorder.[8] A study of 12 murderers established the connection between early severe abuse and DID[9]. A recent psychobiological study shows that dissociative identity disorder (DID) sufferers' "origins of their ailment stem more likely from trauma" than sociogenic or iatrogenic origins[10][11].

DSM inclusion

DID meets all of the guidelines for inclusion in the DSM and is supported by taxometric research.[12] Research has established DID as a valid diagnosis.[12] In one study, DID was found to be a genuine disorder with a constant set of core features.[13]

History

The 19th century saw a number of reported cases of multiple personalities which Rieber estimated would be close to 100.[14]

By the late 19th century there was a general realization that emotionally traumatic experiences could cause long-term disorders which may manifest with a variety of symptoms.[15] Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation.[16]

Starting in about 1927, there was a large increase in the number of reported cases of schizophrenia, which was matched by an equally large decrease in the number of multiple personality reports.[16] Bleuler also included multiple personality in his category of schizophrenia. It was found in the 1980s that MPD patients are often misdiagnosed as suffering from schizophrenia.[16] Multiple personality disorder began to emerge as a separate disorder in the 1970s when an initially small number of clinicians worked to re-establish MPD as a legitimate diagnosis.[16]

Two early personal accounts written about MPD in book form were The 3 Faces of Eve [17] about Chris Sizemore and Sybil: The Classic True Story of a Woman Possessed by Sixteen Personalities [18] about Shirley Mason. These books helped validate the existence of MPD as a legitimate disorder. Another more recent book about Sybil is SYBIL in her own words: The Untold Story of Shirley Mason, Her Multiple Personalities and Paintings [19].

DID in Other Parts of the World

There is strong evidence that DID is not a culture bound phenomenon. Dissociative disorders have been found in more than a dozen countries. [20] DID has been found in China [21] and Turkey. [22]

Physiological Evidence

Physiological evidence has provided additional evidence to back the existence of DID. One review of the literature found "physiologic and ocular differences across alter personalities." [23]. Additional studies have been found showing optical differences in DID cases.[24][25] One study found that "eight of the nine MPD subjects consistently manifested physiologically distinct alter personality states."[26]. Other reviews have found additional physiological differences[27]. Brain mapping has also found physiological differences in alternate personalities[28]. A variety of psychiatric rating scales found that multiple personality is strongly related to childhood trauma rather than to an underlying electrophysiological dysfunction[29]. Dissociative identity disorder patients have been found to have smaller hippocampal and amygdalar volumes than healthy subjects. [30]. The involvement of the orbitalfrontal cortex has been proposed in the development of DID, suggesting a possible neurodevelopmental mechanism that would be responsible for the development of "multiple representations of self." [31] More recent research presents psychobiological evidence indicating actual physical alter states not found in controls. [32] [33] [34]

References

  1. ^ a b c d e f g American Psychiatric Association (2000-06).Diagnostic and Statistical Manual of Mental Disorders DSM-IV TR (Text Revision). Arlington, VA, USA: American Psychiatric Publishing, Inc.. DOI:10.1176/appi.books.9780890423349. ISBN 978-0890420249.
  2. ^ a b c Dissociative Identity Disorder, doctor's reference. Merck.com (2005-11-01).
  3. ^ Pearson, M.L. (1997). Childhood trauma, adult trauma, and dissociation (PDF). Dissociation 10 (1): 58–62
  4. ^ Kluft, RP (2003). Current Issues in Dissociative Identity Disorder (PDF). Bridging Eastern and Western Psychiatry 1 (1): 71–87.
  5. ^ Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM (June 1986). "The clinical phenomenology of multiple personality disorder: review of 100 recent cases". J Clin Psychiatry 47 (6): 285–93. PMID 3711025.
  6. ^ Ross CA, Miller SD, Bjornson L, Reagor P, Fraser GA, Anderson G (March 1991). "Abuse histories in 102 cases of multiple personality disorder". Can J Psychiatry 36 (2): 97–101. PMID 2044042."The patients reported high rates of childhood trauma: 90.2% had been sexually abused, 82.4% physically abused, and 95.1% subjected to one or both forms of child abuse....Multiple personality disorder appears to be a response to chronic trauma originating during a vulnerable period in childhood."
  7. ^ Boon S, Draijer N (March 1993). Multiple personality disorder in The Netherlands: a clinical investigation of 71 patients. Am J Psychiatry 150 (3): 489–94. PMID 8434668."A history of childhood physical and/or sexual abuse was reported by 94.4% of the subjects, and 80.6% met criteria for posttraumatic stress disorder....Patients with multiple personality disorder have a stable set of core symptoms throughout North America as well as in Europe."
  8. ^ Marmer S, Fink D (1994). "Rethinking the comparison of Borderline Personality Disorder and multiple personality disorder". Psychiatr Clin North Am 17 (4): 743–71. PMID 7877901.
  9. ^ Lewis, D., Yeager, C., Swica, Y., Pincus, J. and Lewis, M. (1997). Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder. Am J Psychiatry, 154(12):1703-10. "Signs and symptoms of dissociative identity disorder in childhood and adulthood were corroborated independently and from several sources in all 12 cases; objective evidence of severe abuse was obtained in 11 cases. The subjects had amnesia for most of the abuse and underreported it. Marked changes in writing style and/or signatures were documented in 10 cases. CONCLUSIONS: This study establishes, once and for all, the linkage between early severe abuse and dissociative identity disorder."
  10. ^ Reinders AATS, Willemsen ATM, Vos HPJ, den Boer JA, Nijenhuis ERS (2012) Fact or Factitious? A Psychobiological Study of Authentic and Simulated Dissociative Identity States PLoS ONE 7(6): e39279. doi:10.1371/journal.pone.0039279 "The findings are at odds with the idea that differences among different types of dissociative identity states in DID can be explained by high fantasy proneness, motivated role-enactment, and suggestion. They indicate that DID does not have a sociocultural (e.g., iatrogenic) origin."
  11. ^ Brice, Mikini Scientists Are Beginning to Understand What Causes Multiple Personality Disorder Medical Daily July 02, 2012
  12. ^ a b Gleaves, D.H.; May MC, Cardeña E (2001) An examination of the diagnostic validity of dissociative identity disorder. Clinical Psychology Review 21(4) 577-608
  13. ^ Ross, C.; Norton, G. & Fraser, G. (1989). Evidence against the iatrogenesis of multiple personality disorder (PDF). Dissociation 2 (2): 61–65.
  14. ^ Rieber RW (2002). "The duality of the brain and the multiplicity of minds: can you have it both ways?". History of psychiatry 13 (49 Pt 1): 3–17. DOI:10.1177/0957154X0201304901. PMID 12094818.
  15. ^ Borch-Jacobsen M, Brick D (2000). "How to predict the past: from trauma to repression". History of Psychiatry 11: 15–35. DOI:10.1177/0957154X0001104102.
  16. ^ a b c d Putnam, Frank W. (1989). Diagnosis and Treatment of Multiple Personality Disorder. New York: The Guilford Press, 351. ISBN 0-89862-177-1.
  17. ^ Corbett H., and Cleckley, Hervey M. Thigpen (1957) The 3 Faces of Eve McGraw - Hill Book Co
  18. ^ Schreiber, F. (1973) Sybil: The Classic True Story of a Woman Possessed by Sixteen Personalities Warner Books, NY, NY ISBN 978-0446550123 Information on Sybil
  19. ^ Suraci, P Ph.D. (2011) SYBIL in her own words: The Untold Story of Shirley Mason, Her Multiple Personalities and Paintings Abandoned Ladder. Patrick Suraci's article about his book is Sybil in Her Own Words - Patrick Suraci, Psychologist
  20. ^ Rhodes G, Sar V, Eds (2006) Trauma And Dissociation in a Cross-cultural Perspective: Not Just a North American Phenomenon Routledge ISBN-13: 978-0789034076 "Dispelling the myth that trauma-related dissociative disorders are a North American phenomenon, this unique book travels through more than a dozen countries to analyze the effects of long-lasting traumatization-both natural and man-made-on adults and children."
  21. ^ "Trauma and Dissociation in China" Zeping X, Heqin Y., Zhen W., Zheng Z., Yong X, Jue C, Haiyin Z, Ross, C., Keyes, B., Am J Psychiatry 163:1388-1391, August 2006 doi: 10.1176/appi.ajp.163.8.1388 American Psychiatric Association full text "The findings are not consistent with the sociocognitive, contamination, or iatrogenic models of dissociative identity disorder."
  22. ^ "Frequency of dissociative identity disorder in the general population in Turkey" Akyüza G, Doana O, Sar V, Yargiça L., Tutkuna H. Comprehensive Psychiatry Volume 40, Issue 2, March-April 1999, Pages 151-159 "Our data, derived from a population with no public awareness about dissociative identity disorder and no exposure to systematic psychotherapy, suggest that dissociative identity disorder cannot be considered simply an iatrogenic artifact, a culture-bound syndrome, or a phenomenon induced by media influences."
  23. ^ Birnbaum MH, Thomann K. Visual function in multiple personality disorder. J Am Optom Assoc. 1996 Jun;67(6):327-34 "BACKGROUND: Multiple personality disorder (MPD) is characterized by the existence of two or more personality states that recurrently exchange control over the behavior of the individual. Numerous reports indicate physiological differences, including significant differences in ocular and visual function, across alter personality states in MPD. METHODS: The existing literature was reviewed to provide an overview of the nature and characteristics of MPD, with emphasis on reported physiologic and ocular differences across alter personalities. In addition, a case is reported of an MPD patient seen over a 3-year period. RESULTS: Physiologic differences across alter personality states in MPD include differences in dominant handedness, response to the same medication, allergic sensitivities, autonomic and endocrine function, EEG, VEP, and regional cerebral blood flow. Differences in visual function include variability in visual acuity, refraction, oculomotor status, visual field, color vision, corneal curvature, pupil size, and intraocular pressure in the various personality states of MPD subjects as compared to single personality controls. CONCLUSIONS: The possibility of MPDs should be considered in patients who demonstrate unusual variability in ocular and visual findings, particularly with a positive psychiatric history. The existence of visual and other physiologic differences across alter personalities in MPD offers a unique potential for the study of mind-body relationships."
  24. ^ Miller SD. Optical differences in cases of multiple personality disorder. J Nerv Ment Dis. 1989 Aug;177(8):480-6 "MPD subjects had significantly more variability in visual functioning across alter personalities than did control subjects."
  25. ^ Miller SD, Blackburn T, Scholes G, White GL, Mamalis N. Optical differences in multiple personality disorder. A second look. J Nerv Ment Dis. 1991 Mar;179(3):132-5. "In the present study, data from 20 patients diagnosed with MPD and 20 control subjects role playing MPD were analyzed for statistical and clinical significance. The findings from the present study appear to confirm results from the earlier study that individuals with MPD experience differences in some aspects of visual functioning between alter personalities. The results further confirm that MPD subjects experience more differences across visual measures than control subjects simulating the disorder."
  26. ^ Putnam FW, Zahn TP, Post RM. Psychiatry Res. 1990 Mar;31(3):251-60.Differential autonomic nervous system activity in multiple personality disorder. "Numerous clinical reports suggest that these alter personality states exhibit distinct physiological differences. We investigated differential autonomic nervous system (ANS) activity across nine subjects with MPD and five controls, who produced "alter" personality states by simulation and by hypnosis or deep relaxation. Eight of the nine MPD subjects consistently manifested physiologically distinct alter personality states."
  27. ^ Miller SD, Triggiano PJ. The psychophysiological investigation of multiple personality disorder: review and update. Am J Clin Hypn. 1992 Jul;35(1):47-61. "psychophysiologic differences reported in the literature include changes in cerebral electrical activity, cerebral blood flow, galvanic skin response, skin temperature, event-related potentials, neuroendocrine profiles, thyroid function, response to medication, perception, visual functioning, visual evoked potentials, and in voice, posture, and motor behavior."
  28. ^ Hughes JR, Kuhlman DT, Fichtner CG, Gruenfeld MJ. Brain mapping in a case of multiple personality. Clin Electroencephalogr. 1990 Oct;21(4):200-9. "Brain maps were recorded on a patient with a multiple personality disorder (10 alternate personalities). Maps were recorded with eyes open and eyes closed during 2 different sessions, 2 months apart. Maps from each alternate personality were compared to those of the basic personality "S", some maps were similar and some were different, especially with eyes open. Findings that were replicated in the second session showed differences from 4 personalities, especially in theta and beta 2 frequencies on the left temporal and right posterior regions."
  29. ^ Coons PM, Bowman ES, Milstein V. Multiple personality disorder. A clinical investigation of 50 cases. J Nerv Ment Dis. 1988 Sep;176(9):519-27. "50 consecutive patients with DSM-III multiple personality disorder were assessed using clinical history, psychiatric interview, neurological examination, electroencephalogram, MMPI, intelligence testing, and a variety of psychiatric rating scales. Results revealed that patients with multiple personality are usually women who present with depression, suicide attempts, repeated amnesic episodes, and a history of childhood trauma, particularly sexual abuse....These data suggest that the etiology of multiple personality is strongly related to childhood trauma rather than to an underlying electrophysiological dysfunction."
  30. ^ Vermetten, E, Schmahl, C, Lindner, S, Loewenstein, R, Bremner, J.D. Hippocampal and Amygdalar Volumes in Dissociative Identity Disorder Am J Psychiatry 2006 Apr 163:630-636 "Results: Hippocampal volume was 19.2% smaller and amygdalar volume was 31.6% smaller in the patients with dissociative identity disorder, compared to the healthy subjects. The ratio of hippocampal volume to amygdalar volume was significantly different between groups. Conclusions: The findings are consistent with the presence of smaller hippocampal and amygdalar volumes in patients with dissociative identity disorder, compared with healthy subjects."abstract full text pdf
  31. ^ Forrest, K. Toward an Etiology of Dissociative Identity Disorder: A Neurodevelopmental Approach Consciousness and Cognition 2001, Sept; 10(3):259-293 doi:10.1006/ccog.2001.0493
  32. ^ Reinders AATS, Willemsen ATM, Vos HPJ, den Boer JA, Nijenhuis ERS (2012) Fact or Factitious? A Psychobiological Study of Authentic and Simulated Dissociative Identity States. PLoS ONE 7(6): e39279. doi:10.1371/journal.pone.0039279 "DID patients, high fantasy prone and low fantasy prone controls were studied in two different types of identity states (neutral and trauma-related) in an autobiographical memory script-driven (neutral or trauma-related) imagery paradigm. The controls were instructed to enact the two DID identity states. Twenty-nine subjects participated in the study: 11 patients with DID, 10 high fantasy prone DID simulating controls, and 8 low fantasy prone DID simulating controls. Autonomic and subjective reactions were obtained. Differences in psychophysiological and neural activation patterns were found between the DID patients and both high and low fantasy prone controls. That is, the identity states in DID were not convincingly enacted by DID simulating controls. Thus, important differences regarding regional cerebral bloodflow and psychophysiological responses for different types of identity states in patients with DID were upheld after controlling for DID simulation....The findings are at odds with the idea that differences among different types of dissociative identity states in DID can be explained by high fantasy proneness, motivated role-enactment, and suggestion. They indicate that DID does not have a sociocultural (e.g., iatrogenic) origin."
  33. ^ Reinders AA, Nijenhuis ER, Quak J, Korf J, Haaksma J, Paans AM, Willemsen AT, den Boer JA. Psychobiological characteristics of dissociative identity disorder: a symptom provocation study. Biol Psychiatry. 2006 Oct 1;60(7):730-40. "Psychobiological differences were found for the different DIS (dissociative identity states). Subjective and cardiovascular reactions revealed significant main and interactions effects. Regional cerebral blood flow data revealed different neural networks to be associated with different processing of the neutral and trauma-related memory script by NIS (neutral identity states) and TIS (traumatic identity states)....Patients with DID encompass at least two different DIS. These identities involve different subjective reactions, cardiovascular responses and cerebral activation patterns to a trauma-related memory script."
  34. ^ Reinders AA, Nijenhuis ER, Paans AM, Korf J, Willemsen AT, den Boer JA. Dissociative Identity States. Neuroimage. 2003 Dec;20(4):2119-25. "Having a sense of self is an explicit and high-level functional specialization of the human brain. The anatomical localization of self-awareness and the brain mechanisms involved in consciousness were investigated by functional neuroimaging different emotional mental states of core consciousness in patients with Multiple Personality Disorder (i.e., Dissociative Identity Disorder (DID)). We demonstrate specific changes in localized brain activity consistent with their ability to generate at least two distinct mental states of self-awareness, each with its own access to autobiographical trauma-related memory. Our findings reveal the existence of different regional cerebral blood flow patterns for different senses of self. We present evidence for the medial prefrontal cortex (MPFC) and the posterior associative cortices to have an integral role in conscious experience."

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