Dissociative Identity Disorder
Dissociative identity disorder is the name that DSM-IV-TR uses for what has been commonly known as multiple personality disorder.Dissociative identity disorder is a chronic dissociative disorder, and its cause typically involves a traumatic event, usually childhood physical or sexual abuse.The concept of personality conveys the sense of an integration of the way persons think, feel,and behave and the appreciation of themselves as a unitary being. Person with dissociative identity disorder have two or more distinct personalities. Each of which determines behavior and attitudes during any period in which it is dominant.
Anecdotal and research reports about dissociative disorder have varied in their estimates of the prevalence of the disorder.At one extreme, some investigators believe that dissociative identity disorder is extremely rare.At the other extreme, some believe that dissociative identity disorder is vastly under recognized.Well controlled studies have reported that 0.5to 3 percent of general psychiatric hospital admission meets the diagnostic criteria for dissociative identity disorder are overwhelminglywomen-5:1to9:1female–to–male ratios.
Dissociative identity disorder frequently coexists with other mental disorders, including anxiety disorders, mood disorders, somatoform disorders, sexual dysfunctions, substances-related disorders, eating disorders, sleeping disorders, and post-traumatic stress disorder.
The cause of dissociative identity disorder is unknown, although the histories of the patients invariably(approaching 100 percent) involve a traumatic event,most often in childhood. In general, four types of causative factors have been identified; a traumatic life event, a vulnerability for the disorder to develop, environment factors, and the absence of external support. The traumatic event is usually childhood physical or sexual abuse, commonly incestuous.Other traumatic events can include the death of a close relative or friend during childhood and witnessing a trauma or a death.
The tendency for the disorder to develop may be biologically or psychologically based. The variable ability of persons to be hypnotized maybe one example of a risk factor for the development of dissociative identity disorder.Epilepsy has been hypothesized to be involved in the cause of dissociative identity disorder, and some studies of affected patients have reported a high percentage of abnormal EEG activity. One study of regional central blood flow revealed temporal hyperper fusion is one of the sub personalities but not in the main personality.
Although several studies have found difference in pain sensitivity and other physiological measures among the personalities, the use of these data to prove the existence of dissociative identity disorder should be approached with great caution.
The environmental factors involved in the pathogenesis of dissociative identity disorder are nonspecific and are likely to include such factors as role models and the availability of other mechanisms for dealing with stress. In many cases, the development of dissociative identity seems to have involved the absence of support from significant others, such as parents, siblings, other relatives, and non related persons such as teachers.
3. Diagnosis and Clinical Features
In DSM-IV-TR, the name dissociative identity disorder replaces the earlier multiple personality disorder.As a diagnostic criterion, DSM-IV-TR requires amnestic component,which research has found to be essential to the complete clinical picture. The diagnosis also requires the presence of at least two distinct personality states.
DSM-IV-TR Diagnostic Criteria for Dissociative Identity Disorder
A. The presence of two or more distinct identities or personality states (each with it sown relatively en during pattern of perceiving, relating to,and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person’s behavior.
C. Inability to recall important personal information that is too expensive to be explained by ordinary for getfulness.
D. The disturbance is not due to direct physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication)or a general medical condition (e.g., complex partial seizures).
Despite stories in the popular press about patients with more than 20 personalities, the median number of personalities in dissociative identity disorder is in the range of 5 to 10.Often only two or three of the personalities are evident at diagnosis; the other are recognized during the course of treatment. DSM-IV-TR reports an average of identities for males and15 for females,which may be somewhat high.
In classic cases, each personality has a fully integrated, highly complex set of associated memories and characteristic attitudes,personal relationship,and behavior patterns.
The first appearance of the secondary personality or personalities may be spontaneous or may emerge in relation to what seems to be precipitant (including hypnosis or a drug-assisted interview).The personalities maybe of both sexes, of various races and ages, and from families different from the patient’s family of origin. The most common subordinate personality is childlike.The personalities are often disparate and may even be opposites. In the same person, one of the personalities may be introverted,withdrawn, and sexually inhibited.
4. Differential Diagnosis
The differential diagnosis includes two other dissociative disorders, dissociative amnesia and dissociative fugue.Both of those disorders, however, lack the shift in identity and the awareness of the original identity disorder. Psychotic disorders, notably schizophrenia,maybe confused with dissociative identity disorder only because persons with schizophrenia maybe delusional and believe that they have separate identities or report hearing other personality’s voices. In schizophrenia, a formal thought disorder, chronic social deterioration and other distinguishing signs are present.Recently, clinicians have increasingly appreciated rapidly cycling bipolar disorders,whose symptoms appear similar to those of dissociative identity disorder; interviewing, however, reveals the presence of discrete personalities in patient with dissociative identity disorder. Borderline personality disorder may coexist with dissociative identity disorder. But the alteration of personalities in dissociative identity disorder maybe mistakenly interpreted as nothing more than the irritability of mood and self-image problems characteristic of patients with diagnostic problems. Clear secondary gain raises suspicion, and drug-assisted interviews maybe helpful in making the diagnosis.Among the neurological disorders to consider, complex partial epilepsy is most likely to imitate the symptoms of dissociative identity disorder.
5. Course and Prognosis
Dissociative identity disorder can develop in children as young as 3 years of age. In children, the symptoms may appear trance like and may be accompanied by depressive disorder symptoms, amnesic periods, hallucinatory voices, disavowal/ denial of behaviors, changes in abilities and suicidal or self-injurious behaviors. Although women are more likely to have the disorder than are men, affected children are more likely to be boys than girls; the female predominance develops only in adolescence.Two symptom patterns have been observed in affected female adolescence. One pattern is that of a chaotic life with promiscuity, drug use, somatic symptoms, and suicide attempts. Such patients may be mis classified as having impulse control disorder, schizophrenia, rapidly cycling bipolar.A second pattern is characterized by withdrawal and childlike behaviors. Sometimes, these patients are mis classified as having a mood disorder, a so mato form disorder, or generalized anxiety disorder. In male adolescent with dissociative identity disorder, the symptoms may cause them to have trouble with the law or school officials, and they may eventually end up in prison.
The earlier the onset of dissociative identity disorder, the worse the prognosis is. One or more of personalities may function relatively well while others function marginally.The level of impairment ranges from moderates to serve,the determining variables being the number, type and chronicity of the various personalities.The disorder is considered the most severe and chronic of dissociative disorders, and recovery is generally incomplete. In addition, individual personalities may have their own separate mental disorders;mood disorders, personality disorders, and other dissociative disorders are the most common.
The most effective approaches to dissociate identity disorder involve insight-oriented psychotherapy,often in association with hypnotherapy or drug-assisted interviewing techniques.Hypnotherapy or drug-assisted interviewing can be useful in obtaining additional history, identifying previously unrecognized personalities, and fostering ab reaction psycho therapeutic treatment plan should begin by confirming the diagnosis and by identifying and characterizing the various personalities. If any of the personalities is inclined toward self-destructive or otherwise violent behaviors, the therapist should eng age the patient and the appropriate personalities in treatment contracts about these dangerous behaviors.Hospitalization maybe necessary in some cases.