Dissociative identity disorder ( DID ) is a psychiatric diagnosis that describes a condition in which a single person displays multiple distinct identities or personalities (known as alter egos or alters), 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 the temporary effects of drug use or a general medical condition. The condition first appeared in current medical classification in the 1980 publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) classification, as multiple personality disorder (MPD), which is the term still used by the ICD-10.
There is a great deal of controversy surrounding the topic. There are many commonly disputed points about DID. These viewpoints critical of DID can be quite varied, with some taking the position that DID does not actually exist as a valid medical diagnosis, and others who think that DID may exist but is either always or usually an adverse side effect of therapy. DID diagnoses initially appeared to be almost entirely confined to the North American continent, but later surveys found cases on other continents but at significantly lower rates.
Signs and symptoms
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. Symptoms can include:
- multiple mannerisms, attitudes and beliefs that are not similar to each other
- headaches and other body pains
- distortion or loss of subjective time
- depersonalization
- derealization
- amnesia
- depression
- flashbacks of abuse/trauma
- unexplainable phobias
- sudden anger without a justified cause
- lack of intimacy and personal connections
- frequent panic/anxiety attacks
- auditory hallucinations of the personalities inside their mind
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.
Diagnosis
The diagnosis of Dissociative identity disorder is defined by criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-II used the term multiple personality disorder , the DSM-III grouped 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.
The diagnostic criteria in section 300.14 (dissociative disorders) of the DSM-IV require:
- The presence of two or more distinct identity 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. A patient history, x-rays, blood tests, and other procedures can be used to eliminate the possibility that symptoms are due to traumatic brain injury, medication, sleep deprivation, or intoxicants, all of which can mimic symptoms of DID.
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.
The psychiatric history of individuals diagnosed with DID frequently contain multiple previous diagnoses of various mental disorders and treatment failures.
Screening
The SCID-D 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 (DDIS) 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 (DES) is a simple, quick, and validated 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 15-20 and in one study a DES with a cutoff of 30 missed 46 percent of the positive SCID-D diagnoses and a cutoff of 20 missed 25%. The reliability of the DES in non-clinical samples has been questioned. 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.
Differential diagnoses
Conditions which may present with similar symptoms include borderline personality disorder, and the dissociative conditions of dissociative amnesia and dissociative fugue. The clearest distinction is the lack of discrete formed personalities in these conditions. Malingering may also be considered, and schizophrenia, although those with this last condition will have some form of delusions, hallucinations or thought disorder.
History
Before the 19th century, people exhibiting symptoms of the disorder were believed to be possessed.
An intense interest in spiritualism, parapsychology, and hypnosis continued throughout the 19th and early 20th centuries, 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. 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.
The 19th century saw a number of reported cases of multiple personalities which Rieber estimated would be close to 100. Epilepsy was seen as a factor in some cases and discussion of this connection continues into the present era.
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. These conversion disorders were found to occur in even the most resilient individuals, but with profound effect in someone with emotional instability like Louis Vivé (1863-?) who suffered a traumatic experience as a 13 year-old when he encountered a viper. Vivé was the subject of countless medical papers and became the most studied case of dissociation in the nineteenth century. Between 1880 and 1920, many great international medical conferences devoted a lot of time to sessions on dissociation. 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. One of the first individuals with DID to be scientifically studied was Clara Norton Fowler, under the pseudonym Christine Beauchamp; American neurologist Morton Prince studied Fowler between 1898 and 1904, describing her case study in his 1906 monograph, Dissociation of a Personality . Fowler went on to marry one of her analyst's colleagues.
In the early 20th century interest in dissociation and DID 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. Sigmund Freud recanted his earlier emphasis on dissociation and childhood trauma. 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.
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. A number of factors helped create a large climate of skepticism and disbelief; paralleling the increased suspicion of DID 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 1980s that DID patients are often misdiagnosed as suffering from schizophrenia.
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