Clinical Findings
A. Signs & Symptoms
DID is a disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition and/or sensory–motor functioning. These signs and symptoms may be observed by others or reported by the individual. In addition, the person will experience recurrent gaps in the recall of everyday events, important personal information and/or traumatic events that are inconsistent with ordinary forgetting. This disturbance should not be a normal part of a broadly accepted cultural or religious practice.
(DID) is usually not diagnosed until patients are in their late 20s, but retrospective evidence indicates that it begins much earlier, usually in childhood. Some patients with DID have had years of treatment before the correct diagnosis is made. These patients commonly exhibit transient depression, mood swings, sleep disturbance, nightmares, and suicidal behavior. They are often self-injurious and exhibit a host of dissociative symptoms including amnesia, episodes of “lost time” (i.e., amnesia varying from several minutes to several days), depersonalization, fugue, and hallucinations. Anxiety and its somatic concomitants (e.g., dyspnea, palpitations, chest pain, choking sensations, faintness, tremors) commonly herald a switch of alter personalities. Quasineurologic symptoms such as headache, syncope, pseudoseizures, numbness, paresthesia, diplopia, tunnel vision, and motor weakness are sometimes encountered. Symptoms referable to the cardiorespiratory, gastrointestinal, or reproductive systems may dominate the clinical presentation.
Questioning will reveal that most patients have audiovisual hallucinations and quasidelusions. The auditory hallucinations may be fragments of conversations heard during traumatic experiences or metaphoric expressions of self-disgust in the form of hostile voices that revile and derogate the patient or command her to harm herself, commit suicide, or attack others. Other voices may be conversations between people about the patient, people offering solace, and the weeping and crying of distressed children. Some patients report a sense of being controlled, alterations in their body image, or the conviction that they are being followed or that their lives are threatened by shadowy enemies (e.g., the former perpetrators of alleged “ritual abuse”). Occasional discontinuities of thought and thought “slippages” may be the result of alter switching or the intrusion of traumatic themes into the stream of consciousness, causing microdissociations.
As mentioned earlier in this chapter, these patients may have had many medical and neurologic investigations. Many have been treated for mood disorder, anxiety disorder, or schizophrenia. Some wander from job to job, place to place, and doctor to doctor. Many are prone to repeated victimization by virtue of their poor choice of occupation or consorts.
The cardinal feature of DID is multiple personalities, two or more entities, each of which has a characteristic and separate personality, age, gender, sexual orientation, history, affect, values, and function. However, the original personality state is often the dominant presence. The number of alters is usually about 10, though it may be many more. Typically, the alters are somewhat two-dimensional in quality and include such entities as the host personality; a variety of child personalities (e.g., innocent child, traumatized child, “Pollyanna”); a persecutor; a cross-sex alter; an internal helper; a brazen, promiscuous “hussy”; a variety of demons; and “no one.” The entities usually first emerge during childhood, in the form of imaginary protectors or companions that help the child cope with recurrent experiences of abuse and fear. The alter personalities often switch abruptly, producing a bewildering change in demeanor, sometimes with anxiety and apparent disorganization of thought. Sometimes one alter or several alters will be unaware of the other alters. Often alters will communicate with each other. The complete dramatis personae usually emerge only after therapy.
It can be difficult to elicit alter personalities. The clinician must have a reasonable suspicion that DID is present (e.g., in a patient who exhibits abrupt changes in demeanor, “lost time,” total amnesia for childhood, and many physical symptoms). The exploration of puzzling events or lost time will often elicit an alter. Sometimes the clinician must ask directly to speak to “that part of you” that did something or experienced something.
B. Psychological Testing
See discussion of dissociative amnesia.
Differential Diagnosis (Including Comorbid Conditions)
DID is most likely to be confused with the following conditions: partial complex seizures, schizophrenia, PTSD, bipolar disorder, major depression with psychotic features, Munchausen syndrome, Munchausen syndrome by proxy, and malingering. Partial complex seizures, which usually last no more than a few seconds, may be confused with alter switching; however, other cardinal signs of DID are not seen in epilepsy. Occasionally, telemetry is required.
Patients with DID frequently report the following phenomena: quasidelusions, ideas of being externally controlled, auditory hallucinations involving conversations, comments about the patient cast in the third person, commands, and ideas of thought loss. When these phenomena are associated with the disruption of thinking coincident with alter switching or microdissociation, it is not surprising that patients with DID have often been mistakenly diagnosed as having schizophrenia. DID should be differentiated from schizophrenia by the lack of emotional incongruity; the dramatic, care-eliciting presentation; the history of severe trauma; the alter personalities; and high scores on dissociation scales. Additionally, hallucinations in DID usually start in childhood and follow a fluctuating pattern. However, in schizophrenia variety of psychotic symptoms occur concurrently and usually patient’s functionality deteriorates severely in a later age. Hypnosis is sometimes helpful in distinguishing DID from schizophrenia.
DID and PTSD usually co-occur. These two conditions can be distinguished by lack of hallmark symptoms of PTSD including re-experiencing traumatic events, avoidance of stimuli associated with traumatic events, and hyperarousal. However, PTSD has a dissociative subtype with prominent dissociative symptoms. Therefore, a careful examination is required.
Rapid-cycling bipolar disorder is sometimes confused with the apparent mood swings caused by alter switching in DID. However, in DID mood states switch in response to environment and usually last only from a few seconds to a few hours.
Major depression with psychotic features can be confused with DID if only a superficial diagnostic evaluation has been completed, particularly because many patients with DID have an associated depressive mood. In major depression with psychotic features, the auditory hallucinations and delusions are consistent with the prevailing depressive mood. For example, the patient hears voices derogating him or her for being a bad person and is convinced that he or she has committed an unpardonable sin, is impoverished, is being hounded by tax officials, or is rotting inside. In DID, the hallucinations are often derogatory, but they convey the theme of helpless victimization and command patients to hurt others or themselves.
In some cases of Munchausen syndrome, the pseudopatient has presented himself or herself for medical attention with the symptoms of DID. In some cases of Munchausen syndrome by proxy, a mother presents her child with the symptoms of DID. The imposture is deliberate, but the gain obscure. Satisfaction is apparently obtained from being the center of medical investigations and therapeutic attention, or from being the brave parent of a child with dramatic psychopathology. In malingering, the gain is less enigmatic. The pseudopatient is usually a criminal defendant seeking exculpation on the grounds of insanity.
Treatment
The treatment of DID is the subject of much controversy. Integrative psychotherapy, phasic trauma treatment, and supportive psychotherapy are main psychotherapeutic approaches. While integrative psychotherapy may also involve a phased approach to trauma treatment, it is not the primary focus of the approach. Rather, the therapist may use various therapeutic techniques and modalities throughout the treatment process, depending on the patient’s needs and goals. Integrative psychotherapy is a broader approach that seeks to integrate various theoretical and therapeutic modalities into a holistic treatment plan, while phasic trauma treatment is a specific approach that involves dividing the treatment process into distinct phases.
Phasic trauma treatment focuses on trauma recovery, which is also commonly employed in the treatment of complex posttraumatic disorders, and is considered the standard of care. Patients with DID require a significant amount of psychotherapy, which is why care must be carefully designed to reduce the burden on the health care system. Phasic trauma treatment involves a three-staged approach; Stage 1: stabilization and safety, Stage 2: focus on traumatic memories, Stage3: identity integration and rehabilitation.
Individuals with DID often live in a world of ongoing trauma and are at a heightened risk for various co-morbid conditions and self-destructive behaviors. Prioritizing safety is crucial. Safety agreements, hospitalization, and educating patients about the nature of the disease and treatment plan can be effective in achieving this goal.
The second stage involves an intense focus on traumatic experiences and the recall of life history. This stage requires the achievement of goals from previous stages, a strong therapeutic alliance, control of PTSD symptoms, and a good understanding of the risks and benefits of the treatment by the patient. However, it is important to note that there are potential risks associated with this stage, such as the worsening of symptoms and self-destructive behavior. Therefore, ongoing safety measures and stabilization efforts must be maintained throughout this stage of treatment.
The third stage is re-integration into life. This stage is characterized by the achievement of a more unified sense of self, and the dissociative divisions are resolved. While some individuals achieve a complete fusion of identities, others may only attain a therapeutic resolution that enables them to function adequately.
A powerful body of opinion questions the validity of this diagnosis and questions therapeutic approaches that seek to integrate alters. Kluft describes four approaches to treatment: (1) integrate the alters; (2) seek harmony between the alters; (3) leave the alters alone and focus on improving adaptation to the here-and-now; and (4) regard the alters as artifacts, ignoring them and treating other symptoms (e.g., depression). The last of these approaches is adopted by those who believe that DID is a fictive condition generated or reinforced by the clinicians who treat it. The first three approaches are not mutually exclusive and are adopted in accordance with the patient’s capacity to tolerate the stress of integrating the alter personalities.
Excessively rapid movement in the assessment or treatment of DID will generate resistance. Once DID is identified and the diagnosis communicated, the patient will experience anxiety. Patients with DID tend to be profoundly distrustful of others and may themselves be deceptive. Patients are likely to be hypersensitive to deceit, impatience, or authoritarianism. Clinicians must be able to tolerate uncertainty, normalize any anomalous experiences that patients divulge, and eschew premature reassurance. Many patients report complete amnesia for early and middle childhood. Most are also confused about current experience and are able to report the past in only a piecemeal fashion. Clinicians should inquire about instances of lost time, depersonalization, out-of-body experiences, flashbacks, and hallucinations. Most patients with DID are able to suppress alter switching during brief contact, but they are likely to manifest the phenomenon if the interview session extends over an hour.
It can be useful to draw maps, diagrams, or family trees of the internal system of alters, identifying the components by name, age, and sex. These maps must be revised regularly throughout treatment. When a particular alter acknowledges lost time, another alter may have been internally active during that period. The internal helper alter may be the most reliable informant in the clinician’s attempt to conceptualize the structure of personality fragments. A number of issues should be considered before embarking on integrative therapy. Table 33–1 lists situations in which integrative therapy is contraindicated.
Table 33–1 Contraindications for Integrative Therapy
| Severe ego defect related to early neglect and trauma, and a lifelong reliance on dissociative defenses. |
| Severe, pervasive comorbid pathology, particularly borderline personality disorder, histrionic personality disorder, depression, substance abuse, and eating disorder. |
| Poor environmental support. If the patient is involved in dysfunctional and nonsupportive relationships, retraumatization is likely to occur. There must be at least a moderate level of environmental stability and support. |
| The incapacity of the clinician to tolerate devaluation, acting-out behavior, suicidality, self-injury, and deceptiveness. |
| The inability of patient and clinician to establish and maintain a therapeutic alliance. The therapist must provide a flexible balance between support and interpretation and maintain stable boundaries in interaction with the patient. The patient is likely to test the limits by acting out, seduction, failing to appear for appointments, or devaluing the clinician. |
If supportive therapy is pursued because the patient has a limited potential for integration, the clinician attempts to rehabilitate the patient by strengthening the ego of the host personality and by helping the patient to cope with reality. The emphasis is on stabilization, control of affect and impulse, increased responsibility in everyday behavior, and palliation of distress. Whether the treatment is supportive or integrative, attention must be given to the shame and low self-esteem associated with sexual victimization.
Alters should be directed toward verbal and creative affective expression instead of impulsive, destructive, self-defeating acting out. Each alter represents the expression of a fixed idea: images, thoughts, or associations related to a particular traumatic experience that retains a pristine emotional charge because it has been sequestered from the normal processes of memory decay. The therapist must relate effectively to each of these internal fragments, seeking to improve the contribution of each fragment to overall functioning. The superordinate aim of integrative therapy is to promote the confluence of the entire system, not to strengthen dissociation between alters. The amount of time devoted to the development of greater general ego strength should exceed the amount of time spent in strengthening separate alters.
Persecutory and malevolent alters are best dealt with by patient rechanneling of hostile impulses in more appropriate directions, particularly by expressing rage in words or artistic productions rather than in deeds. Malevolent alters should be confronted gently with the identity confusion that leads them to consider themselves as part of the abuser rather than as part of the patient.
The internal helper alter is a useful ally in treatment and can serve as a consultant to the therapist, providing information about the total system. The ultimate aim of integrative therapy is to reverse the pervasive attachment disruption and splitting that have accompanied abuse. As the patient improves, he or she may begin to grieve for a lost childhood and for normal attachment experiences that were lost or never provided.
The therapist should help the patient develop effective coping skills, using a gentle, educative approach, modeling accurate perception, management of affect, containment of impulse, and the consideration of alternative responses to stress. Inhibited, withdrawn alters will benefit from the encouragement of self-expression and self-assertion. Shame-based alters require the supportive resolution of shame. As the patient becomes more aware of different traumata, a dialogue may occur between the different alters. The therapist should emphasize the need for cooperation. The aim is toward increased dialogue and mutual cooperation.
The abreaction of emotion is an essential component of therapy and is aimed at resolving dissociation and restoring integration. The therapeutic component of abreaction may not be catharsis of feeling but rather the consequent reformulation of traumatic memories. Some patients revert to dissociative trances when they are about to remember and disclose particular traumatic experiences, and spontaneous abreaction may be triggered by reminders of trauma such as anniversaries. However, abreaction without reformulation is unproductive. During abreaction, the therapist’s task is to keep the patient safe, nudge him or her toward reality, and keep him or her in the abreaction until it is concluded. Abreaction is followed by debriefing and exploration of the meaning of the experience. Successful abreaction requires full experience of the affect associated with the event, not just a disembodied memory. Premature initiation of abreaction, or the induction of abreaction in patients who cannot tolerate it, is counterproductive. Table 33–2 summarizes the sequential stages in psychotherapy with these patients.
Table 33–2 Stages in the Integrative Psychotherapy of Dissociative Identity Disorder
|
Late in the therapy, the spontaneous fusing of alters signals readiness for personality unification. Usually this proceeds as two or more alters combine at a time. The therapist must be patient and not press for premature fusion. Full integration involves (1) reduced reliance on the dissociative segregation of experience, (2) the blending of alters into a single nondissociative personality, and (3) the harmonious coexistence of different aspects of the patient’s personality. Integration is relative. Some patients are able to tolerate complete fusion and unification. Others are not capable of full unification but benefit from improved functional integration.
Several other types of psychotherapy may be helpful. In group therapy, groups specifically designed for individuals with DID can be helpful in stabilizing these patients. In contrast, groups consisting of general psychiatric patients have been found to be less successful due to potential disruptions caused by the emergence of alters and the traumatic nature of DID patients.
Family and couples therapy are important parts of the treatment process for individuals with DID. Educating family members about the condition and addressing their concerns can promote the development of healthy coping mechanisms and create a supportive environment for the patient. It is important to emphasize that family members should not interact directly with different alters.
Eye-Movement Desensitization and Reprocessing Therapy (EMDR) is a type of therapy that was originally developed for PTSD treatment. While there is no consensus on its effectiveness for DID patients, some believe that if performed by a well-trained clinician, EMDR can be helpful in well-stabilized DID patients with adult trauma.
Hypnotherapeutic interventions can be useful when rapid diagnosis is required, although it may be preferable to allow the alters to emerge spontaneously. The clinician should explore each alter with regard to the following information: name, age, and sex; developmental origin; dominant affect and perceptual style; survival functions; and unique symptoms and dysfunctions. The clinician should ask to speak to a particular alter identified by name or behavior and should ask for a signal (e.g., a lifted finger) as a signal of the alter’s willingness to appear. Rapport must be developed with each alter. After conducting the appropriate interview, the clinician should ask the alter to resubmerge. Although initially the clinician must treat each alter as if he or she is a separate person, it is important to convey the understanding that each alter is but a dissociated element of the client as a whole.
The medications for treating DID are similar to those used for treating PTSD, with the goal of addressing the symptoms of DID. Table 33–3 lists medications used for DID.
Table 33–3 Medications Used in Dissociative Identity Disorder Treatment
Alpha-Adrenergic Blocking Agents PTSD nightmares and daytime symptoms Selective serotonin reuptake inhibitors Affective disorders (no agent preference) and obsessive–compulsive disorder (fluvoxamine) Tricyclic antidepressants obsessive–compulsive disorder Mood stabilizers PTSD and anxiety Atypical neuroleptics Thought disorder Serotonin antagonist and reuptake inhibitors Sleep problems (Trazodone) Opioid antagonists Self-injurious behavior and addictions (Naltrexone) |
Prognosis
The symptoms of DID typically manifest during childhood. In cases where childhood trauma leads to DID, a positive prognosis can be expected with early intervention and treatment. However, some patients develop histrionic or borderline personalities, with a stormy adulthood. Others are introverted, depressed, and socially avoidant. Males are more likely than females to have a history of episodic violence in the correctional system. Many patients with DID manage to conceal their symptoms for years.