Dissociative identity disorder

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Dissociative identity disorder is a diagnosis described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Revised, as the existence in an individual of two or more distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. At least two of these personalities are considered to routinely take control of the individual's behavior, and there is also some associated memory loss, which is beyond normal forgetfulness. This memory loss is often referred to as "losing time". These symptoms must occur independently of substance abuse, or a general medical condition.

Dissociative identity disorder was initially named multiple personality disorder, and, as referenced above, that name remains in the International Statistical Classification of Diseases and Related Health Problems. Regardless of whether the disorder is termed dissociative identity disorder or multiple personality disorder, it is in no way related to schizophrenia. Although schizophrenia and dissociative identity disorder are commonly linked in the minds of lay people, it is a misconception.

While dissociation is a demonstrable psychiatric condition that is tied to several different disorders, specifically those involving early childhood trauma and anxiety, multiple personality remains controversial. Despite the controversy, many mental health institutes such as McLean Hospital, perhaps the best mental health institute in the world, have wards specifically designated for dissociative identity disorder.

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DSM-IV-TR diagnostic criteria

Due to copyright infringement issues and editorial concerns, the American Psychiatric Association has requested that specific reference to the DSM-IV-TR by Wikipedia be outlinked. The current diagnostic criteria for Dissociative identity disorder published in the Diagnostic and Statistical Manual of Mental Disorders may be found here:

DSM-IV-TR Diagnostic Criteria: Dissociative identity disorder (DID)

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A definition of dissociation

Dissociation is a complex mental process that provides a coping mechanism for individuals confronting painful and/or traumatic situations. It is characterized by a dis-integration of the ego. Ego integration, or more properly ego integrity, can be defined as a person's ability to successfully incorporate external events or social experiences into their perception, and to then present themselves consistently across those events or social situations. A person unable to do this successfully can experience emotional dysregulation, as well as a potential collapse of ego integrity. In other words, this state of emotional dysregulation is, in some cases, so intense that it can precipitate ego dis-integration, or what, in extreme cases, has come to be referred to diagnostically as dissociation.

Dissociation describes a collapse in ego integrity so profound that the personality is considered to literally break apart. For this reason, dissocation is often referred to as "splitting" or "altering". Less profound presentations of this condition are often referred to clinically as disorganization or decompensation. The difference between a psychotic break and a dissociation, or dissociative break, is that, while someone who is experiencing a dissociation is technically pulling away from a situation that s/he cannot manage, some part of the person remains connected to reality. While the psychotic "breaks" from reality, the dissociative disconnects, but not all the way.

Because the person suffering a dissociation does not completely disengage from his/her reality, s/he may appear to have multiple "personalities". In other words, different "people" (read: personalities) to deal with different situations, but generally speaking, no one person (read: personality) who will retreat altogether.

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Defining the controversy

Main article: Multiple personality controversy

One of the primary reasons for the on-going re-categorization of this condition is that there were so few documented cases (research in 1944 showed only 76Template:Ref) of what was then referred to as multiple personality. Although the condition does have a long history stretching back in the literature some 300 years, it remains a rare disorder, affecting less than 1% of the population (Ross, 1997). Conversely, dissociation is now recognized as a symptomatic presentation in response to trauma, extreme emotional stress, and, as noted, in association with emotional dysregulation and borderline personality disorderTemplate:Ref. Often regarded as a dynamic sub-symptomology, it has become more frequent as an ancillary diagnosis, rather than a primary diagnosis. Template:Citeneeded A full blown DID diagnosis, that intends an individual is evidencing quantifiable multiple personalities and presents itself independently of a primary personality disorder, remains rare. Template:Citeneeded

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The DSM re-dress

There is considerable controversy over the validity of the Multiple personality profile as a diagnosis. Unlike the more empirically verifiable mood and personality disorders, dissociation is primarily subjective for both the patient, and the treatment provider. The relationship between dissociation and multiple personality creates conflict regarding the MPD diagnosis. While other disorders do, indeed, require a certain amount of subjective interpretation, those disorders more readily present with generally accepted, objective symptomology. The controversial nature of the dissociation hypothesis evidences itself quite clearly by the manner in which the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders has addressed, and re-dressed, the categorization over the years.

The 2nd Edition of the Diagnostic and Statistical Manual of Mental Disorders, referred to this diagnostic profile as Multiple Personality Disorder. The 3rd Edition of the DSM Manual grouped Multiple Personality Disorder in with the other 4 major dissociative disorders. The current edition, the DSM-IV-TR, categorizes the disorder as Dissociative Identity Disorder. The ICD-10 (International Statistical Classification of Diseases and Related Health Problems) continues to list the condition as multiple personality disorder.

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Other positions

The debate over the validity of this condition, whether as a clinical diagnosis, a symptomatic presentation, a subjective misrepresentation on the part of the patient, or a case of unconscious collusion on the part of the patient and the professional is considerable (see Multiple personality controversy). Unlike other diagnostic categorizations, there is very little in the way of objective, quantifiable evidence for describing the disorder. This makes the disorder itself subjective, as well as its diagnosis.

The main points of disagreement are:

  1. Whether MPD/DID is a real disorder, or just a fad.
  2. If it is real, is the appearance of multiple personalities real or delusional?
  3. If it is real, should it be defined in psychoanalytic terms?
  4. Whether it can be cured.
  5. Whether it should be cured.
  6. Who should primarily define the experience -- therapists, or those who believe that they have multiple personalities?
  7. Whether it is invariably a disorder or simply a way of being.

Skeptics claim that people who present with the appearance of alleged multiple personality may have learned to exhibit the symptoms in return for social reinforcement. This point of view was the original evidence that called into question the overall efficacy of the "Sybil" case , made popular by the media, where the covering psychiatrist Herbert Spiegel Template:Citeneeded stated his position that "Sybil" had been provided with the idea of "personalities" by her treating psychiatrist, Cornelia Wilbur, to describe states of feeling with which she was unfamiliar.

Another view is that multiplicity is not always a disorder (see: "healthy multiplicity") and that it can be normal to experience oneself as multiple, so that it is possible to be multiple without being clinically classifiable as having DID or MPD. From the standpoint of Carl Jung's Analytic Psychology, this position could be characterized as a hyper-awareness of one's personas. However, if this awareness is what healthy multiples are experiencing, then terms like "multiple" or "multiple personality" are inaccurate for them, in that their experience is not related to the clinical state being described here.

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Potential causes of dissociative identity disorder

Dissociative identity disorder is attributed to the interaction of several factors: overwhelming stress, dissociative capacity (including the ability to uncouple one's memories, perceptions, or identity from conscious awareness), the enlistment of steps in normal developmental processes as defenses, and, during childhood, the lack of sufficient nurturing and compassion in response to hurtful experiences or lack of protection against further overwhelming experiences. Children are not born with a sense of a unified identity--it develops from many sources and experiences. In overwhelmed children, its development is obstructed, and many parts of what should have blended into a relatively unified identity remain separate. North American studies show that 97 to 98% of adults with dissociative identity disorder report abuse during childhood and that abuse can be documented for 85% of adults and for 95% of children and adolescents with dissociative identity disorder and other closely related forms of dissociative disorder. Although these data establish childhood abuse as a major cause among North American patients (in some cultures, the consequences of war and disaster play a larger role), they do not mean that all such patients were abused or that all the abuses reported by patients with dissociative identity disorder really happened. Some aspects of some reported abuse experiences may prove to be inaccurate. Also, some patients have not been abused but have experienced an important early loss (such as death of a parent), serious medical illness, or other very stressful events. For example, a patient who required many hospitalizations and operations during childhood may have been severely overwhelmed but not abused.Template:Ref

Human development requires that children be able to integrate complicated and different types of information and experiences successfully. As children achieve cohesive, complex appreciations of themselves and others, they go through phases in which different perceptions and emotions are kept segregated. Each developmental phase may be used to generate different selves. Not every child who experiences abuse or major loss or trauma has the capacity to develop multiple personalities. Patients with dissociative identity disorder can be easily hypnotized. This capacity, closely related to the capacity to dissociate, is thought to be a factor in the development of the disorder. However, most children who have these capacities also have normal adaptive mechanisms, and most are sufficiently protected and soothed by adults to prevent development of dissociative identity disorder.Template:Ref

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Symptoms

Patients often have a remarkable array of symptoms that can resemble other neurologic and psychiatric disorders, such as anxiety disorders, personality disorders, schizophrenic and mood psychoses, and seizure disorders. Symptoms of this particular disorder can include:

  • Depression
  • Anxiety (sweating, rapid pulse, palpitations)
  • phobias
  • panic attacks
  • physical symptoms (severe headaches or other bodily pain)
  • fluctuating levels of function, from highly effective to disabled
  • time distortions, time lapse, and amnesia
  • sexual dysfunction
  • eating disorders
  • posttraumatic stress
  • Suicidal preoccupations and attempts are common
  • episodes of self-mutilation
  • psychoactive substance abuseTemplate:Ref

Other symptoms include: Depersonalization, which 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 and may actually see himself as if he were watching a movie. Derealization refers to experiencing familiar persons and surroundings as if they were unfamiliar and strange or unreal.

Again, doctors must be careful not to assume that a client has MPD or DID simply because they present with some or all of these symptoms.

Persons with dissociative identity disorder are often told of things they have done but do not remember and of notable changes in their behavior. They may discover objects, productions, or 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); and they may have amnesia for events that occurred between their mid-childhood and early adolescence. Amnesia for earlier events is normal and widespread.

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Diagnosis and treatment

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Diagnosis

If symptoms seem to be present, the patient should first be evaluated by performing a complete medical history and physical examination. The various diagnostic tests, such as X-rays and blood tests are used to rule out physical illness or medication side effects as the cause of the symptoms. Certain conditions, including brain diseases, head injuries, drug and alcohol intoxication, and sleep deprivation, can lead to symptoms similar to those of dissociative disorders, including amnesia.

If no physical illness is found, the patient might be referred to a psychiatrist or psychologist. Psychiatrists and psychologists use specially designed interview and personality assessment tools to evaluate a person for a dissociative disorder.Template:Ref

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Prognosis

Patients can be divided into three groups with regard to prognosis. Those in one group have mainly dissociative symptoms and posttraumatic features, generally function well, and generally recover completely with specific treatment. Those in another group have symptoms of other serious psychiatric disorders, such as personality disorders, mood disorders, eating disorders, and substance abuse disorders. They improve more slowly, and treatment may be either less successful or longer and more crisis-ridden. Patients in the third group not only have severe coexisting psychopathology but may also remain enmeshed with their alleged abusers. Treatment is often long and chaotic and aims to help reduce and relieve symptoms more than to achieve integration. Sometimes therapy helps a patient with a poorer prognosis make rapid strides toward recovery.Template:Ref

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Treatment

Perhaps the most common approach to treatment aims to relieve symptoms, to ensure the safety of the individual, and to reconnect the different identities into one well-functioning identity. There are, however, other equally respected treatment modalities that do not depend upon integrating the separate identities. Treatment also aims to help the person safely express and process painful memories, develop new coping and life skills, restore functioning, and improve relationships. The best treatment approach depends on the individual and the severity of his or her symptoms. Treatment is likely to include some combination of the following methods:

  • Psychotherapy: This kind of therapy for mental and emotional disorders uses psychological techniques designed to encourage communication of conflicts and insight into problems.
  • Cognitive therapy: This type of therapy focuses on changing dysfunctional thinking patterns.
  • Medication: There is no medication to treat the dissociative disorders themselves. However, a person with a dissociative disorder who also suffers from depression or anxiety might benefit from treatment with a medication such as an antidepressant or anti-anxiety medicine.
  • Family therapy: This kind of therapy helps to educate the family about the disorder and its causes, as well as to help family members recognize symptoms of a recurrence.
  • Creative therapies such as art therapy or music therapy: These therapies allow the patient to explore and express his or her thoughts and feelings in a safe and creative way.
  • Clinical hypnosis: This is a treatment technique that uses intense relaxation, concentration and focused attention to achieve an altered state of consciousness or awareness, allowing people to explore thoughts, feelings and memories they might have hidden from their conscious minds*Template:Ref

People with DID generally respond well to treatment; however, treatment can be a long and painstaking process. To improve a person's outlook, it is important to treat any other problems or complications, such as depression, anxiety or substance abuse.

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See also


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Entertainment Industry

The disease has become so popular and known, that it has become involved in several films and television series. It is most popular in the daytime television world, where several soap characters suffer from this disease. This started on ABC's One Life to Live, where the main character Victoria Lord blocked out the memory of her father molesting her and created an alternate personality, Nikki Smith. Slezak earned so much praise as Nikki, several storylines would come in the future and Viki inherited several other personalities. Currently her daughter suffers from the same disease and at one point in the show Viki's half-brother Todd Manning (played by Roger Howarth) faked the disease.

Other soaps have experimented with the disease, following OLTL success. They include General Hospital, who had leading character Alexis Davis (played by Nancy Lee Grahn) create an alternate personality called Kristina, caused from the recent death of her sister Kristina Cassadine. It later turned out Alexis was faking the disease to get off the murder of Luis Alcazar.


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References and external links


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Voices of multiples

he:פיצול אישיות nl:Dissociatieve identiteitsstoornis ja:解離性同一性障害 fi:Dissosiatiivinen identiteettihäiriö ru:Раздвоение личности sv:Dissociativ identitetsstörning

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