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DISSOCIATIVE IDENTITY DISORDER (DID)

Angelina Pinhasov, Banafsheh Hosseini, Hieu Ly, Maha Siddiqui, Travis Hall, Yeseul Song

HISTORY
DID was formerly known as Multiple Personality Disorder  It is not a phenomenon of the 21st century  Evidence of its ancient existence is reflected back in the Palaeolithic cave paintings  It is also present in the famous fiction of Dr. Jekyll and Hyde


DEFINITION
What is DID?  A severe form of dissociation that lacks a coherent mental process of ones thoughts, emotions, memories and sense of identity


Question: Which character is this and how does this relate to DID?

DEFINITION CONTINUED


Patient presents two or more distinct personalities or states which often take control over the patients behaviour

One personality is the host, and the others are the alters  Host may or may not be aware of the alters  Going from one personality to the other is called switching


SWITCHING
May occur under stressful situations or in therapy  Switching of personalities may last for a couple of minutes, a couple of hours or up to several weeks at a time  Switching personalities are usually found to be extremely different from the personality of the patient  The individual may still have access to alternate personalities without an overt transition through auditory or visual hallucinations


PREVALENCE & ETIOLOGY

How prevalent is D.I.D?
In a study by Brand et al. (2009) 280 participants diagnosed with D.I.D. were: Females (94% ), Males (5% ) PTSD (89%) Mood Disorder (83% ) Eating Disorder (30% ) Substance Abuse (22% ) Schizophrenia (2%)

What causes DID?

  

Two competing models: 1. Trauma

Model:

Suggests that DID is a defence mechanism in response to experiencing childhood

trauma, sexual, physical

or emotional abuse


Insecure Attachment may also be a risk factor for the development of pathological dissociation**

 2.


Socio-Cognitive Model

Suggests that it is possible to alter ones personality in order to suggest that one has DID  In other words, people may develop DID through learning about this disorder  Leading questions during therapy may also contribute to this

KEY SIGNS AND SYMPTOMS



  

Amnesia (loss of time, or blackouts), whereby the person cant remember periods of time, or even portions of their childhood. Dissociation, which is a mental process where individuals are not fully connected with their thoughts, feelings, behaviours or memories Derealization, which is the feeling that the world is not real or in a haze. Depersonalization, which is the feeling of being detached from your body, as in an out of body experience Switching to different alters, which may appear as sudden changes in mood, behaviour or personality

ASSOCIATED SYMPTOMS
      

Other conditions the individual may also have include: Depression Mood swings Anxiety or panic attacks Thoughts of suicide Alcohol or drug abuse, as an attempt at coping with stress Post-traumatic stress disorder, a condition that may be seen after individuals experience high stress or even life threatening situations Borderline personality disorder, a condition where individuals have severe problems with emotional regulation and controlling their feelings

DIAGNOSIS: DSM IV CRITERIA  Criterion A: Presence of two or more distinct identities  Criterion B: At least two of these identities repeatedly take control of behaviour  Criterion C: greater-than-ordinary forgetfulness and inability to recall important autobiographical memories  Criterion D: Disturbance not attributed to the effects of a substance or a medical condition. In children, imaginary playmates or other fantasy plays are excluded from symptoms.

DIAGNOSIS
How can one be distinguished?
 

No one pattern of symptoms fits all Due to its complex condition, patients are often diagnosed with other conditions before they finally receive their DID diagnosis Other disorders that are often diagnosed along with D.I.D include bipolar personality disorder and posttraumatic stress disorder
Question: What Physiological effects of a general medical condition (e.g. substance use) are some Complex partial seizures similarities Supernatural causes such as trance or possession (e.g. external spirits between these or entities) disorders and Malingering or fabrication due to financial or forensic benefits D.I.D? Factitious disorder, a pattern of help-seeking behaviour

Cannot be due to:

    

SCREENING PROCESS


Initial Phase
 Build

rapport, thorough examination of psychosocial history

Battery of Assessment
 Cognitive

test (WAIS-III)  Objective personality test (MMPI-2)  Projective personality test (TAT, Rorschach)  Self-report measure (DES)  Structured interview (SCID-D-R, DDIS)

ASSESSMENTS OF DID


Structured Clinical Interview for DSM-IV Dissociative Disorder (SCID-D-R)  Gold standard  Addresses all criteria as specified in DSM-IV: amnesia, depersonalization, derealization, identity confusion, identity alteration Dissociative Disorders Interview Schedule (DDIS)  Q. Do you suffer from headaches?  Q. Have you ever had recurrent thoughts of suicide?  Q. Were you sexually abused as a child or adolescent?

TREATMENT: PSYCHOTHERAPY
Most common treatment is the individual oriented psychotherapy  Goal is to integrate all the identities into one unified self  It is NOT appropriate to get rid of an alter  The alter must be integrated more adaptively into the overall personality structure


**PSYCOTHERAPY CONTINUED



PhasePhase-Oriented Treatment Approach:

A three phase process of integrating the identities  Phase I : establishing safety, stabilization, and symptom reduction: goal is to create a safe environment  Phase II: Confronting, working through, and integrating traumatic memories  Phase III: Integration and rehabilitation

**TREATMENT: PSYCHOTHERAPY
Techniques include: 1. Cognitive behavioural therapy:

Involves changing the patients beliefs or cognitions to manage stressful experiences

2. Hypnosis:

Used as a facilitator of psychotherapy for purposes such as calming, soothing and ego strengthening

**TREATMENT: PSYCHOTHERAPY
Techniques continued 3. EMDR (Eye movement desensitization remedy):


Assumes that adaptive resolution of many problems is achieved through trauma processing with the eight phase protocol.


  

Incorporates:
Use of alternating bilateral stimulation (ABS) Alternating bilateral auditory or tactile stimulation 8 Phase treatment approach

4. Psychopharmacology


May be an option for some patients

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BRAIN REGIONS CONTINUED

 Regional

cerebral blood flow (rCBF)

was observed in a study by Sar et al. (2006)  The rCBF ratio was decreased in the frontal and occipital regions of DID patients compared to healthy controls

BRAIN REGIONS INVOLVED:



Small hippocampal volume has often been associated with stress-related psychiatric disorders A study by Vermettan et al. (2006) showed 19.2% smaller hippocampal volume and 31.6% smaller amygdalar volume compared to healthy controls

AMYGDALA
 The primary role is the processing and memory of emotional reactions

Question: How would a smaller amygdalar volume relate to DID?

HIPPOCAMPUS:
 The main function involves the consolidation of information from short term memory to long term memory

Question: How would a smaller hippocampal volume relate to DID?

PATIENT WITH D.I.D SWITCHES ALTERS IN BRAIN SCANNER



http://www.youtube.com/watch?v=zhM0xp5vXqY  Duration: 3:40-5:25 seconds

WHAT ABOUT SOCIAL IMPACTS?

HOW WILL D.I.D AFFECT ONE IN A SOCIAL CONTEXT?

SOCIAL IMPACTS OF D.I.D



 

Feeling of detachment from self in stressful situations Periods of mental absence in school or at work; loss of productivity and performance unrelated to intelligence Memory defragmentation, experiences of finding oneself in strange places without recollection of how one got there Unpleasant feelings associated with dissociation (e.g. floors moving up and down) Diluted experience of sense or emotions Suicidal thoughts and self-mutilation

PROGRAMS
Centre for Treatment of Sexual Abuse and Childhood 376 ChurchillTrauma
Avenue Suite 104 Ottawa, ON K1Z 5C3

INTERESTING FACTS
Typical types of alters:
    

A depressed, exhausted host. A strong, angry protector. A scared, hurt child. A helper. An internal persecutor who blames one or more of the alters for the abuse they have endured. (Sometimes named after the actual abuser)

Source: http://allpsych.com/journal/did.html

INTERESTING FACTS CONTINUED

A few symptoms of alters:


Voices: It is possible to hear many distinct and separate voices, of all ages talking at the same time. Physical Differences: each alter may present itself uniquely through different body movements and facial expressions Handwriting Differences: alter and host may have different handwriting styles!

D.I.D & MALINGERING



Malingering is a medical term that refers to exaggerating

the symptoms of a mental or physical disorder in order to avoid duty, work or any other interest behind it.




Hard to detect
While malingered individuals tend to express their symptoms, put emphasis on early child abuse and comfortably talk about their alter personalities, genuine patients tend to be more reluctant about revealing their symptoms

Question: How does this create a problem is society?

LEGAL IMPACT OF D.I.D

State v. Milligan (1978)

William

Milligan, a 23-year old man from Ohio Charged for 9 counts of rapes on a university campus Pleaded innocent based on the lack of integrated personality
Alter

in control was allegedly Adelena, a 19-year old lesbian

Found

NOT GUILTY BY THE REASON OF INSANITY

Milligan was admitted to the psychiatric unit and released after having 24 alters fused.

LEGAL IMPACT OF D.I.D CONTINUED

In support of D.I.D. Acts performed unconsciously have been used as evidence to acquit Involuntary criminal behavior A mental disease = no responsibility for the behavior In opposition to D.I.D. State of consciousness or personality in control does not matter Inability of the alter to distinguish right from wrong Many cases often lack scientific evidence on the diagnosis

Forensic evaluators should

be different from treating physician or psychiatrist remain objective, free of biases, opened to all possibilities involve multidisciplinary and multi-technique approach

THE END

REFERENCES
 

 

  

 

Ann Thomas M.D. (2001). Factitious and Malingered Dissociative Identity Disorder. Journal of Trauma & Dissociation. 2(4), 59-77. Brand, B. L., Armstrong, J. G., & Loewenstein, R. J. (2006). Psychological assessment of patients with dissociative identity disorder. Psychiatric Clinics of North America, 29, 145-168. Brand et al. (2009). A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians. Psychological Trauma: Theory, Research, Practice, and Policy, 1(2), 153-171. Gold et al. (2012). Contextual Treatment of Dissociative Identity Disorder. Journal of Trauma and Dissociation, 2:4, 5-36. International Society for the Study of Trauma and Dissociation (2011): Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision: Summary Version. Journal of Trauma & Dissociation, 12:2, 188-212. Lakshmanan et al. (2010). Collaborative Effort of Psychotherapy and Psychopharmacology. Psychiatry, 733-37. Nickeas, R. , & Stickley, T. (2006). Becoming one person: living with dissociative identity disorder. Journal of Psychiatric and Mental Health Nursing, 13, 180-187. Richard P. Kluft M.D. (2000). The Psychoanalytic Psychotherapy of Dissociative Identity Disorder in the Context of Trauma Therapy. Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 20:2, 259-286. Sar et al. (2006). Frontal and occipital perfusion changes in dissociative identity disorder. Psychiatry Research: Neuroimaging, 156, 217-223. Vermetten et al. (2006). Hippocampal and Amygdalar Volumes in Dissociative Identity Disorder. The American Journal of Psychiatry, 163, 630-636.

REFERENCES CONTINUED
 

Farrell, H. M. (2011). Dissociative identity disorder: Medicolegal challenges. Journal of American Academy of Psychiatry and the Law, 39, 402-406. Frankel, A. S., & Dalenberg, C. (2006). The forensic evaluation of dissociation and persons diagnosed with dissociative identity disorder: Searching for convergence. Psychiatric Clinics of North America, 29, 169-184.