Dissociative identity disorder

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Dissociative identity disorder is defined in the DSM-IV-TR as the presence of two or more personality states or distinct identities that repeatedly take control of a patient's behavior, so that the patient has an inability to recall selected memories or personal information. In dissociative identity disorders, the lack of recall is too great to be explained by normal forgetfulness, and is more complete and total than any type of role-specific memories. To fit the diagnosis, the disorder also cannot be due to the direct physical effects of a general medical condition or substance.[1] While the National Library of Medicine's Medical Subject Headings (MeSH) browser accepts this condition as a recognized illness, it substitutes the term multiple personality disorder; a literature search in some medical databases may prefer the latter term.[2]

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.[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]

Though the majority of scientific sources have found dissociative identity disorder to be a legitimate diagnosis, there has been some controversy as to its origins and inclusion in the DSM.

Symptomology

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.[3]

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.[3]

Causes

The causes of dissociative identity disorder are theoretically linked with the interaction of overwhelming stress, traumatic antecedents,[4] insufficient childhood nurturing, and an innate ability to dissociate memories or experiences from consciousness.[3] Prolonged child abuse is frequently a factor, with a very high percentage of patients reporting documented abuse[5] 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. The DSM also states that "controversy surrounds the accuracy" of the reports of child abuse, because childhood memories can possibly be distorted and some sufferers of this disorder are "highly hypnotizable and especially vulnerable to suggestive influences." [1] Research has shown that DID is characterized by reports of extensive childhood trauma, usually child abuse.[6][7][8] 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.[9] Some consider it a culture bound and iatrogenic syndrome [10] while others contest this idea [11][12]

Prevalence

The DSM-IV-TR states that the sharp rise in reported cases in the United States has been given different interpretations. Some believe that the greater awareness of the diagnosis among those in the mental health field has caused the identification of certain cases that previously were not diagnosed. Others believe that it has been overdiagnosed in those that are highly suggestible. [1] Others have claimed that individuals suffering from DID were previously misdiagnosed. [13]

DSM inclusion

DID meets all of the guidelines for inclusion in the DSM and is supported by taxometric research.[14] Research has established DID as a valid diagnosis.[14] In one study, DID was found to be a genuine disorder with a constant set of core features.[11]

History

The 19th century saw a number of reported cases of multiple personalities which Rieber estimated would be close to 100.[15]

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.[16] Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation.[13] 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.[13] 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.[13] 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.[13]

Controversy

Some skeptical of the diagnosis have stated that the DID diagnosis is not a reliable one and that the arguments to support the concept are illogical.[17] Some have critiqued the DID diagnosis, stating that it was found primarily in the United States and is a cultural construct.[18], yet more recent research has shown different diagnostic rates in other parts of the world.[19][20] Others have stated that the research on DID does not support the ideas that DID is a construct of either psychotherapy or the media[21] or they have critiqued those skeptical of the DID diagnosis and theories of iatrogenesis and social construct.[22] One researcher states that the evidence backing the traumatic origins of DID is "plagued by poor methodology." [23], however the DSM states that DID sufferers have "past histories of sexual or physical abuse (that) are confirmed by objective evidence." [1]

Notes

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 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. ↑ Anonymous (2024), Dissociative identity disorder (English). Medical Subject Headings. U.S. National Library of Medicine.
  3. ↑ 3.0 3.1 3.2 Dissociative Identity Disorder, doctor's reference. Merck.com (2005-11-01).
  4. ↑ Pearson, M.L. (1997). "Childhood trauma, adult trauma, and dissociation" (PDF). Dissociation 10 (1): 58–62:.
  5. ↑ Kluft, RP (2003). "Current Issues in Dissociative Identity Disorder" (PDF). Bridging Eastern and Western Psychiatry 1 (1): 71–87.
  6. ↑ 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. [e]
  7. ↑ 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. [e]
  8. ↑ 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. [e]
  9. ↑ 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.
  10. ↑ Piper A, Merskey H (2004). "The persistence of folly: a critical examination of dissociative identity disorder. Part I. The excesses of an improbable concept" (pdf). Canadian journal of psychiatry. Revue canadienne de psychiatrie 49 (9): 592–600. PMID 15503730. [e]
  11. ↑ 11.0 11.1 Ross, C.; Norton, G. & Fraser, G. (1989). "Evidence against the iatrogenesis of multiple personality disorder" (PDF). Dissociation 2 (2): 61–65. Cite error: Invalid <ref> tag; name "Ross" defined multiple times with different content
  12. ↑ Braun, B.G. (1989). "Dissociation: Vol. 2, No. 2, p. 066-069: Iatrophilia and Iatrophobia in the diagnosis and treatment of MPD" (PDF).
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Putnam, Frank W. (1989). Diagnosis and Treatment of Multiple Personality Disorder. New York: The Guilford Press, 351. ISBN 0-89862-177-1. 
  14. ↑ 14.0 14.1 Gleaves, D.H.; May MC, Cardeña E (2001). "An examination of the diagnostic validity of dissociative identity disorder." 21 (4): 577-608.
  15. ↑ 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. Research Blogging.
  16. ↑ 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. Research Blogging.
  17. ↑ Piper A, Merskey H (2004). "The persistence of folly: critical examination of dissociative identity disorder. Part II. The defence and decline of multiple personality or dissociative identity disorder" (pdf). Canadian journal of psychiatry. Revue canadienne de psychiatrie 49 (10): 678–83. PMID 15560314. [e]
  18. ↑ Spanos, Nicholas P. (2001). Multiple Identities & False Memories: A Sociocognitive Perspective. American Psychological Association (APA). ISBN 1-55798-893-5. 
  19. ↑ Friedl MC, Draijer N (2000). "Dissociative disorders in Dutch psychiatric inpatients". The American journal of psychiatry 157 (6): 1012–3. DOI:10.1176/appi.ajp.157.6.1012. PMID 10831486. Research Blogging.
  20. ↑ Sar V, Koyuncu A, Ozturk E, et al (2007). "Dissociative disorders in the psychiatric emergency ward". General hospital psychiatry 29 (1): 45–50. DOI:10.1016/j.genhosppsych.2006.10.009. PMID 17189745. Research Blogging.
  21. ↑ Gleaves, D. (July 1996). "The sociocognitive model of dissociative identity disorder: a reexamination of the evidence". Psychological Bulletin 120 (1): 42–59. DOI:10.1037/0033-2909.120.1.42. PMID 8711016. Research Blogging.
  22. ↑ Brown, D; Frischholz E, Scheflin A. (1999). "Iatrogenic dissociative identity disorder - an evaluation of the scientific evidence". The Journal of Psychiatry and Law XXVII No. 3-4 (Fall-Winter 1999): 549–637.
  23. ↑ Kihlstrom, J. F. (April 2005). "Dissociative Disorders". Clinical Psychology `: 227-253.
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