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Dissociative
identity disorder, formerly called multiple personality disorder,
is characterized by 2 or more identities or personalities that alternate
and by an inability to recall important personal information relating
to some of the identities. The cause is typically overwhelming childhood
trauma. Diagnosis is based on history, sometimes supplemented by
hypnosis or drug-facilitated interviewing. Treatment is psychotherapy,
sometimes combined with drug therapy.
What is not known by one identity may be known by another. Some identities may appear to know and interact with others in an elaborate inner world.
Etiology
Dissociative identity disorder is attributed to the interaction of overwhelming stress (typically extreme mistreatment), insufficient nurturing and compassion in response to overwhelmingly hurtful experiences during childhood, and dissociative capacity (ability to uncouple one's memories, perceptions, or identity from conscious awareness).
Children are not born with a sense of a unified identity—it develops from many sources and experiences. In overwhelmed children, many parts of what should have blended together remain separate. Chronic and severe abuse (physical, sexual, or emotional) during childhood is frequently reported by and documented in patients with dissociative identity disorder. Some patients have not been abused but have experienced an important early loss (such as death of a parent), serious medical illness, or other overwhelmingly stressful events.
In contrast to most children who achieve cohesive, complex appreciation of themselves and others, severely mistreated children may go through phases in which different perceptions and emotions are kept segregated. Such children may develop an ability to escape the mistreatment by “going away” or “retreating” into their own mind. Each developmental phase may be used to generate different selves.
Symptoms and Signs
Several symptoms are characteristic: fluctuating symptom pictures; fluctuating levels of function, from highly effective to disabled; severe headaches or other bodily pain; time distortions, time lapses, and amnesia; and depersonalization and derealization. Depersonalization refers to feeling unreal, removed from one's self, and detached from one's physical and mental processes. The patient feels like an observer of his life, as if he were watching himself in a movie. Patients may even feel as if transiently they do not inhabit their bodies. Derealization refers to experiencing familiar people and surroundings as if they were unfamiliar, strange, or unreal.
Patients may discover objects, productions, or samples of handwriting that they cannot account for or recognize. They may refer to themselves in the first person plural (we) or in the third person (he, she, they).
The switching of identities and the amnestic barriers between them frequently result in chaotic lives. Because the identities often interact with each other, patients typically report hearing inner conversations between other personalities, which comment on or address the patient. Thus, a patient may be misdiagnosed with psychosis. Although these voices are experienced as hallucinations, they have a distinctly different quality from the typical hallucinations of psychotic disorders like schizophrenia.
Patients often have a remarkable array of symptoms that can resemble those of anxiety disorders, mood disorders, posttraumatic stress disorder, personality disorders, eating disorders, schizophrenia, and seizure disorders. Suicidal ideation and attempts are common, as are episodes of self-mutilation. Many affected patients abuse substances.
Diagnosis
Patients typically give histories of having had 3 or more different mental disorders and of prior treatment failures. The skepticism of some physicians regarding the validity of dissociative identity disorder can also contribute to misdiagnosis.
The diagnosis requires specific questions about dissociative phenomena. Prolonged interviews, hypnosis, or drug-facilitated ( methohexital ) interviews are sometimes used, and the patient may be asked to keep a journal between visits. All of these measures encourage a shift of personality states during the evaluation. Specially designed questionnaires can help.
The psychiatrist may also attempt to directly contact other identities by asking to speak to the part of the mind involved in behaviors for which the patient had amnesia or that were experienced in a depersonalized or derealized fashion.
Prognosis
Symptoms wax and wane spontaneously, but dissociative identity disorder does not resolve spontaneously. Patients can be divided into 3 groups. Those in the 1st group have mainly dissociative symptoms and posttraumatic features and generally function well and recover completely with treatment. Those in a 2nd group have dissociative symptoms combined with symptoms of other disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. They improve more slowly, and treatment may be less successful or longer and more crisis-ridden. Patients in the 3rd group not only have severe symptoms from coexisting mental disorders but also may remain emotionally attached to their alleged abusers. These patients often require long-term treatment, which typically aims to help control symptoms more than to achieve integration.
Treatment
Integration of the identity states is the most desirable outcome. Medications help manage symptoms of depression, anxiety, impulsivity, and substance abuse, but treatment to achieve integration centers on psychotherapy. For patients who cannot or will not strive for integration, treatment aims to facilitate cooperation and collaboration among the identities and to reduce symptoms.
The first priority of psychotherapy is to stabilize the patient and ensure safety, before evaluating traumatic experiences and exploring problematic identities. Some patients benefit from hospitalization, in which continuous support and monitoring are provided as painful memories are addressed. Hypnosis is often used to explore traumatic memories and diffuse their effect. Hypnosis may also help with accessing the identities, facilitating communication between them, and stabilizing and interpreting them. As the reasons for the dissociations are addressed, therapy can move to the point at which the patient's selves and relationships and social functioning can be reconnected, integrated, and rehabilitated. Some integration occurs spontaneously. Integration can be encouraged by negotiating with and arranging the unification of the identities or facilitated with imagery and hypnotic suggestion.
Last full review/revision November 2005
Content last modified November 2005
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