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14-September-2008 12:50:30 - Dissociative identity disorder Not to be confused with Dissocial personality disorder. Dissociative identity disorder Classification and external resources ICD-10 F44.8 ICD-9 300.14 MeSH D009105 Dissociative Identity Disorder DID, by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders DSM, is a psychiatric diagnosis that describes a condition in which a single person displays multiple distinct identities or personalities, each with its own pattern of perceiving and interacting with the environment. The diagnosis requires that at least two personalities routinely take control of the individual's behavior with an associated memory loss that goes beyond normal forgetfulness; in addition, symptoms cannot be due to substance abuse or medical condition. Earlier versions of the DSM named the condition multiple personality disorder MPD, and the term is still used by the ICD-10. There is controversy around the existence, the possible causes, the prevalence across cultures, and the epidemiology of the condition. Contents 1 Classification 2 Signs and symptoms 3 Causes 4 Pathophysiology 5 Diagnosis 6 Screening 7 Treatment 8 Prognosis 9 Epidemiology 10 History 11 Cultural references 12 Controversy 13 See also 14 Notes 15 Further reading 16 External links Classification Some believe that DID should be re-classified as a trauma disorder.1 Signs and symptoms Individuals 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. Symptoms can include:2 multiple mannerisms, attitudes and beliefs that are dissimilar to each other headaches and other body pains distortion or loss of subjective time depersonalization amnesia depression Patients may experience an extremely broad array of other symptoms that resemble epilepsy, schizophrenia, anxiety, Mood disorders, posttraumatic stress, personality, and eating disorders.2 Causes The causes of dissociative identity disorder have not been identified, but are theoretically linked with the interaction of overwhelming stress, traumatic antecedents,1 insufficient childhood nurturing, and an innate ability to dissociate memories or experiences from consciousness.2 Prolonged childhood abuse is frequently a factor, with a very high percentage of patients reporting documented abuse34 often confirmed by objective evidence.5 Others believe DID is created iatrogenically by therapists using certain treatment techniques with suggestible patients,6748 though this idea is neither confirmed nor universally accepted.9101112133 Pathophysiology Reviews of the literature have discussed the findings of various psychophysiologic investigations of DID.1415 Many of the investigations include testing and observation in the one person but with different alters. Different alter states have shown distinct physiological markers16 and some EEG studies have shown distinct differences between alters in some subjects,1718 while other subjects' patterns were consistent across alters.19 Another study concluded that the differences involved intensity of concentration, mood changes, degree of muscle tension, and duration of recording, rather than some inherent difference between the brains of persons with multiple personalities and those of persons with single personalities.20 Brain imaging studies have corroborated the transitions of identity in some DID sufferers.21 One EEG study comparing DID with hysteria showed differences between the two diagnoses.22 A postulated link between epilepsy and DID has been disputed by a number of authors.2324 Some brain imaging studies have shown differing cerebral blood flow with different alters,252627 and distinct differences overall between subjects with DID and a healthy control group.28 A different imaging study showed that findings of smaller hippocampal volumes in patients with a history of exposure to traumatic stress and an accompanying stress-related psychiatric disorder were also demonstrated in DID.29 This study also found smaller amygdala volumes. Studies have demonstrated various changes in visual parameters between alters.303132 One twin study showed herable factors were present in DID.33 Diagnosis The diagnostic criteria in DSM-IV Dissociative disorders section 300.14 require: The presence of two or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self. At least two of these identities or personality states recurrently take control of the person's behavior. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. The disturbance is not due to the 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. In children, the symptoms are not attributable to imaginary playmates or other fantasy play.5 A patient history, x-rays, blood tests, and other procedures can be used to eliminate symptoms being due to traumatic brain injury, medication, sleep deprivation, or intoxicants, all of which can mimic symptoms of DID.34 Diagnosis should be performed by a psychiatrist or psychologist who may use specially designed interviews such as the SCID-D and personality assessment tools to evaluate a person for a dissociative disorder.34 The psychiatric history of individuals diagnosed with DID frequently contain multiple previous diagnoses of various mental disorders and treatment failures. The belief by some doctors that the diagnosis is fallacious may contribute to the frequency of its misdiagnosis.2 DID is frequently misdiagnosed as bipolar disorder due to mood changes between alter states being mistaken for the cyclical mood changes accompanying bipolarity. Another frequent misdiagnosis is psychotic disorder as dialogues between alters may be mistaken for auditory hallucinations.25 Screening The SCID-D35 may be used to make a diagnosis. This interview takes about 30 to 90 minutes depending on the subject's experiences. The Dissociative Disorders Interview Schedule DDIS36 is a highly structured interview which discriminates between various DSM-IV diagnoses. The DDIS can usually be administered in 30-45 minutes. The Dissociative Experiences Scale DES37 is a simple, quick, and validated38 questionnaire that has been widely used to screen for dissociative symptoms. Tests such as the DES provide a quick method of screening subjects so that the more time-consuming structured clinical interview can be used in the group with high DES scores. Depending on where the cutoff is set, people who would subsequently be diagnosed can be missed. An early recommended cutoff was 15-2039 and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D35 diagnoses and a cutoff of 20 missed 25%.40 The reliability of the DES in non-clinical samples has been questioned.41 There is also a DES scale for children and DES scale for adolescents. One study argued that old and new trauma may interact, causing higher DID item test scores.1 Treatment Treatment of DID may attempt to reconnect the identities of the disparate alters into a single functioning identity and/or may be symptomatic to relieve the distressing aspects of the condition and ensure the safety of the individual. Treatment methods may include psychotherapy and medications for comorbid disorders.34 Some behavior therapists initially use behavioral treatments such as only responding to a single identity, and using more traditional therapy once a consistent response is established.42 It has been stated that treatment recommendations that follow from models that do not believe in the traumatic origins of DID might be harmful due to the fact that they ignore the posttraumatic symptomatology of people with DID.10 Prognosis DID does not resolve spontaneously, and symptoms vary over time. Individuals with primarily dissociative symptoms and features of posttraumatic stress disorder normally recover with treatment. Those with comorbid addictions, personality, mood, or eating disorders face a longer, slower, and more complicated recovery process. Individuals still attached to abusers face the poorest prognosis; treatment may be long-term and consist solely of symptom relief rather than personality integration. Changes in identity, loss of memory, and awaking in unexplained locations and situations often leads to chaotic personal lives.2 Epidemiology The DSM does not provide an estimate, and suggests different explanations for the sharp rise in incidence of DID. Possible reasons suggested for the increase in incidence and prevalence of DID over time include the condition being misdiagnosed as schizophrenia, bipolar, or other such disorders in the past, and/or an increase in awareness of DID and child sexual abuse leading to earlier, more accurate diagnosis. Other clinicians believe that DID is an iatrogenic condition overdiagnosed in highly suggestive individuals,5 though there is disagreement over the ability of the condition to be induced by hypnosis.913 Figures from psychiatric populations inpatients and outpatients show a wide diversity from different countries: Country Prevalence Source study India 0.015% Adityanjee et al 198943 Switzerland 0.05-0.1% Modestin 199244 China 0.4% Xiao et al 200645 Germany 0.9% Gast et al 200146 The Netherlands 2% Friedl Draijer 200047 U.S. 10% Bliss Jeppsen 198548 U.S. 6-8% Ross et al 199249 U.S. 6-10% Foote et al. 200640 Turkey 14% Sar et al 200750 Figures from the general population show less diversity: Country Prevalence Source study Canada 1% Ross 199151 Turkey male 0.4% Akyuz et al 199952 Turkey female 1.1% Sar et al 200753 Dissociative identity disorder can be found in a sizable minority of patients in drug abuse treatment facilities.4 History An intense interest in spiritualism, parapsychology, and hypnosis continued throughout the 19th and early 20th centuries,54 running in parallel with John Locke's views that there was an association of ideas requiring the coexistence of feelings with awareness of the feelings.55 Hypnosis, which was pioneered in the late 1700s by Franz Mesmer and Armand-Marie Jacques de Chastenet, Marques de Puységur, challenged Locke's association of ideas. Hypnotists observed second personalities emerging during hypnosis and wondered how two minds could coexist.54 Some of these hypnotherapists reported treating people with symptoms that might now be diagnosed as DID.5556 The 19th century saw a number of reported cases of multiple personalities which Rieber55 estimated would be close to 100. Epilepsy was seen as a factor in some cases55 and discussion of this connection continues into the present era.1924 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.57 Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation. 58 It was in this climate that Jean-Martin Charcot introduced his ideas of the impact of nervous shocks as a cause for a variety of neurological conditions. One of Charcot's students, Pierre Janet, took these ideas and went on to develop his own theories of dissociation.59 In the early 20th century interest in dissociation and MPD waned for a number of reasons. After Charcot's death in 1893, many of his hysterical patients were exposed as frauds and Janet's association with Charcot tarnished his theories of dissociation.54 Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma.54 Freud, a man who actively promoted his ideas and enlisted the help of others, won out over the lone wolf Janet who did not train students in a teaching hospital.55 Psychologists found that science was hard to reconcile with a soul or an unconscious. In 1910, Eugen Bleuler introduced the term schizophrenia to replace dementia praecox and a review of the Index Medicus from 1903 through 1978 showed a dramatic decline in the number of reports of multiple personality after the diagnosis of schizophrenia caught on, especially in the United States.60 A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of MPD was the decline of interest in dissociation as a laboratory and clinical phenomenon. 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. Bleuler also included multiple personality in his category of schizophrenia. It was found in the 1980's that MPD patients are often misdiagnosed as suffering from schizophrenia.58 The public, however, were exposed to psychological ideas which took their interest. Mary Shelley's Frankenstein, Robert Louis Stevenson's Strange Case of Dr Jekyll and Mr Hyde, and many short stories by Edgar Allan Poe, had a formidable impact.55 In 1957, with the publication of the book The Three Faces of Eve, and the popular movie which followed it, the American public's interest in multiple personality was revived. Multiple personality disorder began to emerge as a separate disorder in the 1970's when an initially small number of clinicians worked to re-establish MPD as a legitimate diagnosis.58 In 1974, the highly influential book Sybil was published and six years later the diagnosis of multiple personality disorder was included in the DSM. As media coverage spiked, diagnoses climbed. There were 200 reported cases of MPD from 1880 to 1979, and 20,000 from 1980 to 1990.61 Joan Acocella reports that 40,000 cases were diagnosed from 1985 to 1995.62 The majority of diagnoses are made in North America, particularly the United States, and in English-speaking countries more generally63 with reports recently emerging from other countries.43444546475052 One of the primary reasons for the ongoing recategorization of this condition is that there were once so few documented cases research in 1944 showed only 7662 of what was once referred to as multiple personality. Dissociation is recognized as a symptomatic presentation in response to trauma, extreme emotional stress, and, as noted, in association with emotional dysregulation and borderline personality disorder64. In one study, DID was found to be a genuine disorder with a constant set of core features.11 The DSM-II used the term multiple personality disorder, the DSM-III the diagnosis with the other four major dissociative disorders, and the DSM-IV-TR categorizes it as dissociative identity disorder. The ICD-10 continues to list the condition as multiple personality disorder. Cultural references Main article: Dissociative identity disorder in fiction Controversy Main article: Multiple personality controversy DID is a controversial diagnosis and condition, with much of the literature on DID being generated and published in North America, to the extent that it was regarded as a phenomenon confined to that continent.65546 Even within North American psychiatrists, there is a lack of consensus regarding the validity of DID,6667 with some researchers considering it a culture bound, iatrogenic condition67 though this idea has not been accepted by a number of researchers in the field.9101112133 The DSM states that patients with DID often report having a history of severe physical and sexual abuse. There is a controversy around the accuracy of these reports, as memories of childhood may be distorted and DID patients are easy to hypnotize and are very vulnerable to suggestion in certain situations. 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.5 There is a controversy around the accuracy of these reports, as memories, especially in childhood, have been scientifically documented by the studies of Elizabeth Loftus and others to be easily distorted. Diagnoses of multiple personalities peaked in the mid 1990s then sharply declined and may now not have widespread scientific acceptance.68 See also Psychology portal Depersonalization Dissociation psychology Dissociative disorders Fugue state Identity social science Identity formation Psychogenic amnesia Self-concept Splitting psychology Truddi Chase Notes ^ a b c Pearson, M.L. 1997. Childhood trauma, adult trauma, and dissociation. Dissociation 10 1: 58-62:. Retrieved on 2008-06-01. ^ a b c d e f Dissociative Identity Disorder, doctor's reference. Merck.com 2005-11-01. Retrieved on 2007-12-07. ^ a b c Kluft, RP 2003. Current Issues in Dissociative Identity Disorder. Bridging Eastern and Western Psychiatry 1 1: 71-87. Retrieved on 2008-05-09. ^ a b c Dissociative Identity Disorder, patient's reference. Merck.com 2003-02-01. Retrieved on 2007-12-07. ^ a b c d e Not only does it affect 'Naomi' but the personality disorder of 'Anessa' also affects those with the name of 'Liana' American Psychiatric Association 2000-06. Diagnostic and Statistical Manual of Mental Disorders DSM-IV TR Text Revision. Arlington, VA, USA: American Psychiatric Publishing, Inc., 527-30. doi:10.1176/appi.books.9780890423349. ISBN 978-0890420249. Retrieved on 2007-12-27. ^ a b c 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. ^ a b 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. ^ Carroll, RT 2007-12-03. Multiple personality disorder dissociative identity disorder. Skeptic's Dictionary. Retrieved on 2008-01-22. ^ a b c 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. ^ a b c 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. ^ a b c Ross, C.; Norton, G. Fraser, G. 1989. Evidence against the iatrogenesis of multiple personality disorder. Dissociation 2 2: 61-65. 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Neurophysiological and neuropsychological study of two cases of multiple personality syndrome and comparison with chronic hysteria. International journal of psychophysiology : official journal of the International Organization of Psychophysiology 10 2: 151-61. PMID 2272862. ^ Ross CA, Heber S, Anderson G, et al 1989. Differentiating multiple personality disorder and complex partial seizures. General hospital psychiatry 11 1: 54-8. PMID 2912820. ^ a b Devinsky O, Putnam F, Grafman J, Bromfield E, Theodore WH 1989. Dissociative states and epilepsy. Neurology 39 6: 835-40. PMID 2725878. ^ Reinders AA, Nijenhuis ER, Paans AM, Korf J, Willemsen AT, den Boer JA 2003. One brain, two selves. Neuroimage 20 4: 2119-25. doi:10.1016/j.neuroimage.2003.08.021. PMID 14683715. ^ Reinders AA, Nijenhuis ER, Quak J, et al 2006. Psychobiological characteristics of dissociative identity disorder: a symptom provocation study. Biol. Psychiatry 60 7: 730-40. doi:10.1016/j.biopsych.2005.12.019. 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Visual function in multiple personality disorder. Journal of the American Optometric Association 67 6: 327-34. PMID 8888853. ^ Jang KL, Paris J, Zweig-Frank H, Livesley WJ 1998. Twin study of dissociative experience. J. Nerv. Ment. Dis. 186 6: 345-51. doi:10.1097/00005053-199806000-00004. PMID 9653418. ^ a b c Mental Health: Dissociative Identity Disorder Multiple Personality Disorder. Webmd.com. Retrieved on 2007-12-10. ^ a b Steinberg M, Rounsaville B, Cicchetti DV 1990. The Structured Clinical Interview for DSM-III-R Dissociative Disorders: preliminary report on a new diagnostic instrument. The American journal of psychiatry 147 1: 76-82. PMID 2293792. ^ Ross CA, Ellason JW 2005. Discriminating among diagnostic categories using the Dissociative Disorders Interview Schedule. Psychological reports 96 2: 445-53. doi:10.2466/PR0.96.2.445-453. PMID 15941122. ^ Bernstein EM, Putnam FW 1986. Development, reliability, and validity of a dissociation scale. J. Nerv. Ment. 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Functional Analytic Psychotherapy: Creating Intense and Curative Therapeutic Relationships. Springer. ISBN 0306438577. ^ a b Adityanjee, Raju GS, Khandelwal SK 1989. Current status of multiple personality disorder in India. The American journal of psychiatry 146 12: 1607-10. PMID 2589555. ^ a b Modestin J 1992. Multiple personality disorder in Switzerland. The American journal of psychiatry 149 1: 88-92. PMID 1728191. ^ a b Xiao Z, Yan H, Wang Z, et al 2006. Trauma and dissociation in China. The American journal of psychiatry 163 8: 1388-91. doi:10.1176/appi.ajp.163.8.1388. PMID 16877651. ^ a b Gast U, Rodewald F, Nickel V, Emrich HM 2001. Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic. J. Nerv. Ment. Dis. 189 4: 249-57. doi:10.1097/00005053-200104000-00007. PMID 11339321. ^ a b 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. ^ Bliss EL, Jeppsen EA 1985. Prevalence of multiple personality among inpatients and outpatients. The American journal of psychiatry 142 2: 250-1. PMID 3970252. ^ Ross CA, Anderson G, Fleisher WP, Norton GR 1992. Dissociative experiences among psychiatric inpatients. General hospital psychiatry 14 5: 350-4. PMID 1521791. ^ a b 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. ^ Ross CA 1991. Epidemiology of multiple personality disorder and dissociation. Psychiatr. Clin. North Am. 14 3: 503-17. PMID 1946021. ^ a b Akyüz G, DoÄŸan O, Sar V, Yargiç LI, Tutkun H 1999. Frequency of dissociative identity disorder in the general population in Turkey. Comprehensive psychiatry 40 2: 151-9. doi:10.1016/S0010-440X9990120-7. PMID 10080263. ^ Sar V, Akyüz G, DoÄŸan O 2007. Prevalence of dissociative disorders among women in the general population. Psychiatry Res 149 1-3: 169-76. doi:10.1016/j.psychres.2006.01.005. PMID 17157389. ^ a b c d e Atchison M, McFarlane AC 1994. A review of dissociation and dissociative disorders. The Australian and New Zealand journal of psychiatry 28 4: 591-9. doi:10.3109/00048679409080782. PMID 7794202. ^ a b c d e f 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 10.1177/0957154X0201304901. PMID 12094818. ^ Carlson ET 1989. Multiple personality and hypnosis: the first one hundred years. Journal of the history of the behavioral sciences 25 4: 315-22. doi:10.1002/1520-669619891025:4315::AID-JHBS23002504023.0.CO;2-H. PMID 2677129. ^ 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. ^ a b c Putnam, Frank W. 1989. Diagnosis and Treatment of Multiple Personality Disorder. New York: The Guilford Press, 351. ISBN 0-89862-177-1. ^ van der Kolk BA, van der Hart O 1989. Pierre Janet and the breakdown of adaptation in psychological trauma. The American journal of psychiatry 146 12: 1530-40. PMID 2686473. ^ Rosenbaum M 1980. The role of the term schizophrenia in the decline of diagnoses of multiple personality. Arch. Gen. Psychiatry 37 12: 1383-5. PMID 7004385. ^ Adams, C 2003. Does multiple personality disorder really exist?. The Straight Dope. Retrieved on 2008-01-22. ^ a b Acocella, JR 1999. Creating hysteria: women and multiple personality disorder. San Francisco: Jossey-Bass Publishers. ISBN 0-7879-4794-6. ^ Spanos, Nicholas P.. Multiple Identities False Memories: A Sociocognitive Perspective. American Psychological Association APA. ISBN 1557983402. ^ 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. ^ Boon S, Draijer N 1991. Diagnosing dissociative disorders in The Netherlands: a pilot study with the Structured Clinical Interview for DSM-III-R Dissociative Disorders. The American journal of psychiatry 148 4: 458-62. PMID 2006691. ^ Pope HG, Oliva PS, Hudson JI, Bodkin JA, Gruber AJ 1999. Attitudes toward DSM-IV dissociative disorders diagnoses among board-certified American psychiatrists. The American journal of psychiatry 156 2: 321-3. PMID 9989574. ^ Lalonde JK, Hudson JI, Gigante RA, Pope HG 2001. Canadian and American psychiatrists' attitudes toward dissociative disorders diagnoses. Canadian journal of psychiatry. Revue canadienne de psychiatrie 46 5: 407-12. PMID 11441778. ^ Pope HG, Barry S, Bodkin A, Hudson JI 2006. Tracking scientific interest in the dissociative disorders: a study of scientific publication output 1984-2003. Psychother Psychosom 75 1: 19-24. doi:10.1159/000089223. PMID 16361871. Further reading Goettmann, B. A.; Greaves, B. G., Coons M. P. 1994. Multiple personality and dissociation, 1791-1992: a complete bibliography. Lutherville, MD: The Sidran Press, 85. ISBN 0-9629164-5-5. External links Look up multiple personality in Wiktionary, the free dictionary. Dissociative identity disorder at the Open Directory Project International Society for the Study of Trauma and Dissociation Retrieved from http://en..org/wiki/Dissociative_identity_disorder Categories: Dissociative disorders Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية Deutsch Español Français Bahasa Indonesia עברית Nederlands 日本語 Polski Português РуÑ?Ñ?кий Suomi Svenska اردو ä¸æ–‡ This page was last modified on 13 September 2008, at 14:50
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