Dissociative Identity Disorder

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Dissociative identity disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder, which was from 1980-1994. The International Classification of Diseases,(ICD) still uses this label, <ref name=ICD10/> even though the ICD-11 is expected to change it. The term is misleading. No one can have more than one personality, nor is the disorder a personality disorder. {{See also| Multiple Personality Disorder}}Dissociative identity disorder is a disorder of mental states, where a individual switches from one distinct state to another distinct state, which distinguished it from OSDD/DDNOS, BPD and PTSD. <ref name=Dell2009/>{{Rp|557-570,487-494,471-486}} {{See also| Dissociative Identity Disorder}} is the consequence of inadequate caregiving, resulting in a lack of attachment, an inability to process trauma memories and a changed personality, where two or more distinct states, and two or more less than distinct states ensue. Genetics, if they play a part at all, are influenced directly by environmental action and inaction. This disorder is not selective, and will strike any infant that is subjected to "certain" terrifying boundaries and conditions. [2] [3]

DID is conceptualized as a childhood onset, posttraumatic developmental disorder in which the child is unable to consolidate a unified sense of selfNormal sense of self is experienced as alterations in consciousness, but the sense of self remains stable and consistent. In individuals with a Dissociative disorder the sense of self alternates and is inconsistent across time and experience. <ref name=Dell2009/>{{Rp|160}} There is no unified sense of self. due to severe, chronic childhood abuse"interactions in which one person behaves in a violent, demeaning or invasive manner towards another person (e.g. child or partner)" <ref name=VandenBos2007/>, often involving a caretaker. DissociationDissociation is a compartmentalization of experience, where elements of a trauma are not integrated into a unified sense of the self. <ref name=Dell2009/>{{Rp|4-810, 127}}The lay persons idea of [[dissociation]], that which exists in the normal mind, is not what is referred to in this document. <ref name=Dell2009/>{{Rp|233-234}} during and after the repeated episodes of abuse allows the child to psychologically detach from the emotional and physical pain, in turn potentially resulting in alterations in memory"Memory is not a static thing, but an active set of processes." <ref name=Siegel/>{{Rp|51}} "Our earliest experiences shape not only what we remember, but also how we remember and how we shape the narrative of our lives. Memory can be seen as the way the mind encodes elements of experience into various forms of representation. As a child develops, the mind begins to create a sense of continuity across time, linking past experiences with present perceptions and anticipations of the future." <ref name=Siegel/>{{Rp|11}} encoding and retrieval. Over time, this leads to fragmentation and compartmentalization of memory, as well as difficulty retrieving memory. Exposure to early, typically chronic, trauma results in the elaboration of discrete physiological, psychological, and behavioral states that can persist and, over later development, become increasingly developed, ultimately resulting in dissociative emotional/behavioral/memory self-states. -Bethany L Brand and Ruth A Lanius [4]
FMRI scans capture distinct states switchingFull dissociation is when an alter switches with the alter currently in executive control, resulting in amnesia for that alter. (see executive control) <ref name=Howell2011/>{{Rp|4-6}} In full dissociation, there is complete amnesia between dissociated states, which is a <ref name=Dell2009/>{{Rp|228}} criteria for a diagnosis of dissociative identity disorder in the DSM-5. {{See also| Dissociation}} with one another in DIDDissociative identity disorder is a disorder of mental states, where a individual switches from one distinct state to another distinct state, which distinguished it from OSDD/DDNOS, BPD and PTSD. <ref name=Dell2009/>{{Rp|557-570,487-494,471-486}} {{See also| Dissociative Identity Disorder}}. DID is the only disorder where 2 or more distinct states have ever been observed switching. The smaller lit up areas on the images are seen in all the Dissociative and Trauma Disorders. These are "less than distinct states," or as the DSM calls them, "discontinuities in sense of self and agency." In OSDD images show 1 distinct state only, and it switches with the less than distinct states at random times without ever needing a triggerA reactivating stimulus in trauma disorders. A stimulus in the present which is a reminder of a part of a traumatic [[memory]], which can cause the part of an individual that hold the trauma (EP) to feel as if it is reliving past trauma experience. <ref name=Boon2011/>{{Rp|166-186}} Also known as a trauma trigger.. All states in OSDD can literally be lit up on a scan at one time. When a trigger does occur then the affected states comes forward, and either takes over for the distinct state or it influences it. In PTSD there is 1 less than distinct state and 1 distinct state, and both stay lit until a trigger causes the less than distinct state to respond (flashbackA flashback is a reactivated traumatic memory experienced as intrusive thoughts, feelings, or images associated with past trauma, but lacking a sense of being from the past. <ref name=Siegel2012/>{{Rp|30}} It is experienced by the state referred to as the EP. {{See also | Grounding techniques}} or other reaction to unprocessed memories) and then the distinct state disappears from the image and the less than distinct state takes over. In the complex version of PTSD there is always 2 less than distinct states, which stay together in the scans, but otherwise act the same as in PTSD. BPD involves 1 distinct state that is always visible until the individual is in distress, and then 2 less than distinct states show up together, but don't take over as is seen in PTSD, and so there are no flashbacks or other symptoms reacting from the unprocessed trauma memories, but there are other dissociative symptoms. [5] [2] [6] [7] [8] [9]

A short history and where we are today

Today research has focused on identifying differences between distinct states and less than distinct states. It was 1940 when Charles Samuel Myers (born March 13 1873, London and died October, 12 1946, Winsford in Somersetshire) said:

"Now and again there occur alterations of the 'emotional' and the 'apparently normal' personalities, the return of the former often heralded by severe headache, dizziness or by a hysterical convulsion. On its return, the 'apparently normal' personality (meaning personality statePersonality state - Many terms are used that have the same meaning including: parts, selves, part of the Self, subselves, selves, parts of the personality, subpersonalities, sides, internal Self-states, identities, states, ego states, part of the mind, and entity. The personality is an agglomeration of many personality states. <ref name=Noricks2011/>{{Rp|1}}) may recall, as in a dream, the distressing experiences revived during the temporary intrusionParts of the [[personality]] influence each other, whether they are aware of others or not. Any part may intrude on, and influence the experience of the part that is functioning in daily life, without taking full control of functioning. <ref name=Boon2011/>{{Rp|27}} In dissociative identity disorder and other disorders, dissociative symptoms are felt when one dissociated state intrudes into the experience of another. Intrusions occur in perceptions, ideas, wishes, needs, movements and behaviors. <ref name=Boon2011/>{{Rp|18}} In partial dissociation, amnesia is not present. <ref name=Dell2009/>{{Rp|228}} of the 'emotional' personality (again meaning personality state)." - Myers (1940) [10]:22

Around the same time Pierre Marie Félix Janet, (born May 30, 1859, Paris, France and died February 24, 1947, Paris) a French psychologistPsychologists usually have an advanced degree, most commonly in clinical psychology, and often has extensive training in research. Psychologists use psychotherapy (often referred to as "talk therapy" or just "therapy") to treat mental disorders. Some psychologists specialize in psychological testing and evaluation.<ref name=AboutPsychiatry/> and neurologist was explaining something similar and he went into amazing detail. Ellert Nijenhuis, Onno van der Hart and Kathy Steele brought Janet's and Myers work back to the spotlight in their 2006 book, "The Haunted SelfThe DSM-IV uses the term identity in its definition of dissociation. (see identity) <ref name=Dell2009/>{{Rp|127}}," and they reintroduced the idea of two explicitly different types of personality states, using the terminology introduced by Charles Samuel Myers. [6]:vii-xi In Structural Dissociation, a distinct state is referred to as the "apparently normal part of the personality" and the less than distinct state is known as the "emotional part of the personality". [6]:28-43

It's well understood today that the only disorder with two distinct states is dissociative identity disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder, which was from 1980-1994. The International Classification of Diseases,(ICD) still uses this label, <ref name=ICD10/> even though the ICD-11 is expected to change it. The term is misleading. No one can have more than one personality, nor is the disorder a personality disorder. {{See also| Multiple Personality Disorder}}Dissociative identity disorder is a disorder of mental states, where a individual switches from one distinct state to another distinct state, which distinguished it from OSDD/DDNOS, BPD and PTSD. <ref name=Dell2009/>{{Rp|557-570,487-494,471-486}} {{See also| Dissociative Identity Disorder}}, [11] [2]:1-243 [6]:8 but not everyone shares the same terminology, and so to make it easier to understand, on this page the terms distinct state and less than distinct state will be used. In 2014 there has been a great deal of work introduced from neurologists and other researchers including Ulrich F. Lanius, Sandra L. Paulsen, and Frank M. Corrigan. In their book "Neurobiology and Treatment of Traumatic Dissociation Toward an Embodied Self," they present important information about the function of the midbrain and it's role in dissociative identity disorder. To summarize this idea briefly, the midbrain is responsible for the creation of a second distinct state and any future distinct states. [2]:34
Amnesia and dissociative identity disorder
The 2006 version of the theory of Structural Dissociation explained amnesia in dissociative identity disorder as a function of unnoticed passed time, [6]:91-94 but since then, Ellert Nijenhuis and Onno van der Hart have changed their stance to agree with the following. [12] [6]:8Dissociative amnesia involves less than distinct states, but it's true amnesia that exists between distinct states, and it is this which defines dissociative identity disorder. A knowledgeable diagnostician understands that for a correct diagnosis of dissociative identity disorder, it's the distinct states that are sought out and not the amnesia itself. [6]:73-88 Individuals with posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), and other specified dissociative disorder (OSDD) often report amnesia, but what they experience is dissociative amnesia rather than true amnesia. Dissociative amnesia is caused by the effects of traumatic events both in past and present time, such as flashbacks, [2]:1-130 where true amnesia is caused by a full switching of distinct states with one another.

Dissociative identity disorder is the only disorder with two or more distinct personality states

An individual with dissociative identity disorder must be observed switching from one distinct state to another distinct state to ever obtain an accurate diagnosis. [6] Brain scans have recently called for a strong acceptance of the two different types of states defined by their separateness and how their variations act visually on a scan. An fMRIA type of neuroimaging. Neuroimaging is an approach that allows researchers to view areas of the brain that become active during behavioral events such as emotion, perception and cognition. It is part of the science of in psychophysiology.<ref name=Andreassi2010/> is a meticulous method of telling a distinct state from a less than distinct state, [12] but a knowledgeable and trained trauma therapistPyschotherapists are often called a 'therapists'. These professionals may be a psychiatrist, psychologist or other mental health professional who have specialist training in psychotherapy. They are qualified to work with patients in a clinical setting. should be highly proficient in telling one from the other without it. [13] Once a therapist can identify states confidently, they can then observe, watching to see if switches exist from a distinct state to another distinct state, and if not then the diagnosis would be other specified dissociative disorder. A qualified diagnostician would never confused dissociative identity disorder or other specified dissociative disorder with borderline personality disorder (BPD), schizophrenia, or posttraumatic stress disorder (PTSD). [10] The ISSTD and other organizations do offer training for mental health professionals.

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Distinct personality states

Distinct states are highly phobic of "anything of emotion" that they do not relate to as an "acceptable" and self acknowledged pattern of reliability. [14] [6]:216-336 Fear directs how all dissociated personality statesThe highly dissociated and compartmentalized personality states found in dissociative identity disorder occur in various mental disorders. Other terms meaning the same thing include: dissociated part, dissociated part of self and disaggregate self-state, but often the same terms used for non-dissociated state are used for dissociated states. {{See also| Alters}} {{See also| Personality}} relate to each other, but distinct states appear to be lacking what is needed to control fear, or at least the type of fear that is primate in nature, and so distinct states are literally riddled with phobiaPhobia of dissociated states is evident in all dissociative disorders, but in dissociative identity disorder it is highly evident.. [6]:291-298, 216-336 [12] Phobic inhibitions prevent distinct states from sharing information with "subjectively offensive states" within their realm. [6]:216-336Distinct states have two ways of being present; one realm is the inner world (subconscious) and the other is "the face" of the individual. The inner world is directed by innate and primal fear which has properties to help fend off "offensive states" which are subjectively intrusive. The phobia between the states is thought to define the partitions between each dissociated state. Once fear is reduced to an "acceptable level," through trauma memory processing and integration, then intimacy between states can progress. [6]:216-336
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Less than distinct personality states are either observing or experiencing

In the inner world there are both distinct and less than distinct states, and each of these types of states are fearful of one another to one extent or the other, and also of like-states, for that matter. Fear directs a dissociated statesThe highly dissociated and compartmentalized personality states found in dissociative identity disorder occur in various mental disorders. Other terms meaning the same thing include: dissociated part, dissociated part of self and disaggregate self-state, but often the same terms used for non-dissociated state are used for dissociated states. {{See also| Alters}} {{See also| Personality}} very nature and frames its disposition and character. [6]:89-108 When created, less than distinct states take the form of either observing or experiencing. [2] [6]:66-71

  • Observing states: Individuals with dissociative identity disorder often describe at least one observing state [2]:258-259 that has learned to harness innate skills and become "powerful" in the inner world, but all observing states seem to have this potential. There have been many labels attached to these states including inner self helper, and hidden observer. An observing state could be described as embellished, extravagant, complex, curious, learning and even limitless. [7]
  • Experiencing state" If an experiencing state were compared to an observing state it would be described as basic and unyielding, and tending to stay in the "experience in which they evolved," not in which they were created. A state is not made at the point in time in which a trauma occurs, but later when the individual is overwhelmed with unprocessed trauma memories. They stay "stuck." so to say, because their memories are triggeredA reactivating stimulus in trauma disorders. A stimulus in the present which is a reminder of a part of a traumatic [[memory]], which can cause the part of an individual that hold the trauma (EP) to feel as if it is reliving past trauma experience. <ref name=Boon2011/>{{Rp|166-186}} Also known as a trauma trigger. by "like" occurrences. In dissociative identity disorder, unlike other specified dissociative disorder, less than distinct states are not "stuck" at certain ages, but instead remain within a certain range of emotional experiences. [2]
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Symptoms

Distinct states act adult-like when "wearing the face of an adult", and are the ones that react to situations where an adult is needed, [6] however a fascinating tidbit, is that individuals with dissociative identity disorder report that the same distinct states that are adult-like while out, can, and usually do, act and "look" child-like while in the inner world. Less than distinct states are, due to their evolution, always child-like and highly aware that they are in distress, both while in the inner world and while out and in executive controlThe state that has control of an individual at that moment has executive control, and the dissociated state most often in executive control is commonly called the host. <ref name=Boon2011/>{{Rp|27}}. It's important to understand that distinct states in dissociative identity disorder are rarely able to tell anything is wrong with them, no matter how ill the individual actually is, due to the massive phobia these states have in response to other states within the personality systemAll states that make up the personality in an individual.. [6]:73-88 [2]:1-212, 243-498 [9] [6]:73-88

The two types of states in dissociative identity disorder are directed by dissociation, and those states appear to be responsible for a whole spectrum of symptoms including true amnesia between distinct states, dissociative amnesia between less than distinct states and between a less than distinct state and a distinct state. [2] Also, the communication between any two states, voices heard between any state that is out and another state that is in the inner world; a phenomena that will only occur after a great deal of integration work. Note that voices (communication between the state out and a state in the inner world) is also experienced during early childhood before dissociative boundaries become intensified between the states, which tends to happen with age. [2] Self alteration, another symptom, means the individual switches to address a presenting external situation. The ability to notice this is commonly referred to as "consciousnesses," which is simply a point along the process of integrationIntegration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." <ref name=Siegel2012/>{{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. <ref name=Siegel2012/>{{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." <ref name=Siegel2012/>{{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. <ref name=Howell2011/>{{Rp|143}} where communication between parts is now possible, experienced as the state that is out being able to communicate with the states in the inner world. [2] FlashbacksA flashback is a reactivated traumatic memory experienced as intrusive thoughts, feelings, or images associated with past trauma, but lacking a sense of being from the past. <ref name=Siegel2012/>{{Rp|30}} It is experienced by the state referred to as the EP. {{See also | Grounding techniques}} are common in dissociative identity disorder and tend to become glaringly obvious once integration work begins, and settle down as work progresses, whereas the symptom called a "trance"periods of absence-like staring and unresponsiveness; well documented in severely dissociative people for over 100 years"<ref name=Dell2009/>{{Rp|229}}" (staring off into space) is more prominent prior to any therapy. Derealization and depersonalization are feelings that are hard to identify for a distinct state, because this type of state is devoid of personal acknowledgment in the disorder, which again is due to the intense phobic barriers found in dissociative identity disorder, and so they can't recognize what is going on in relation to themselves, but again, with a great deal of integration, these two "feelings" (symptoms) can be better identified. Identity confusionDefined as "a feeling of uncertainty, puzzlement, or conflict about one's own identity. "<ref name=Steinberg1994/>{{Rp|13}}. The structured clinical interview for the dissociative disorders and other diagnostic tools assess identity confusion. {{See also| Identity confusion}} {{See also| Diagnosis}} is unmistakeably present in this disorder, but the distinct state that is out won't notice it until a great deal of integration work has been done. It's important to understand that without trauma memory processing and integration work an individual with dissociative identity disorder is not going to recognize symptoms in themselves, which is in contrast to the other complex Dissociative Disorder: other specified dissociative disorder. [2] Somatic symptoms are also present, and can range from a simple itch to complete blindness, deafness or an inability to walk or move limbs. [15]

The individual with dissociative identity disorder is often successful, with distinct states functioning efficiently at work, where they tend to dominate consciousness, but they fail in their private relationships and personal lives where child-like states, (less than distinct states), interject vehement emotions into their world, and at times take over completely, acting in behalf of the individual. [2]

Symptom confusion and introjected disorders

Symptoms can be confusing if the state that is out is modeling behavior learned early in childhood. Common "interjected behaviors" (somatic illness) are borderline personality disorder, narcissistic personality disorder, antisocial personality disorder, and other disorders that caregivers of severely traumatized children might have. The individual who is modeling, does not have the disorder, but they "think" (an insanely complicated process) they do, and so they exhibit the symptoms. [2] It is possible for the person with dissociative identity disorder to have a comorbidComorbid means the the presence of more than one psychiatric diagnosis at once, with substance use this is often referred to as "dual diagnosis" Also see [[Cormobid]]. disorder, but if this is the case then all states in the individual will always have that disorder. [2] Somatic illness is also responsible for psychological blindness, deafness, and an inability to move limbs, among other things, but unless all states have the "disability", it's just the very complicated process of "modeling learned behavior." [15]

OSDD, BPD, PTSD, Schizophrenia

Mental health professionals with inadequate training have misdiagnosed dissociative identity disorder throughout history, [16] but with today's knowledge this should be a thing of the past. Below are common disorders that use to be confused with dissociative identity disorder.

Dissociative identity disorder is not rare; it is thought to occur in 1% to 3% of the world's general population. [19] The DSMPublished by the American Psychiatric Association as the standard classification of mental disorders used by US mental health professionals. It consists of diagnostic classification, the diagnostic criteria sets, and descriptive text. The DSM-II listed multiple personality disorder as a symptom of hysterical neurosis, dissociative type. The DSM-III (1980) moved Multiple Personality Disorder from a symptom to its own disorder. The DSM-IV changed the name to dissociative identity disorder (1994) and the DSM-5 (May 2013) updated the listing to current standards. <ref name=DSMIV/> <ref name=DSM5/> <ref name=Dell2009/>{{Rp|384}}-5 reports that a US community was tested and the findings revealed 1.5% with dissociative identity disorder and it was almost equal among genders. [20]:294

Etiology

Even though the vast membership of the International Society for the Study of Trauma and Dissociation (ISSTD) do not agree on everything to do with dissociative identity disorder, they do all agree that dissociative identity disorder is caused by early childhood traumaThe most fundamental effect of trauma is dissociation, so we define trauma as the event(s) that cause dissociation. <ref name=Howell2011/>{{Rp|75}} The original trauma in those with dissociative identity disorder was failure of secure attachment with a primary attachment figure in early childhood. <ref name=Howell2011/>{{Rp|83}}. [19]:133 [17]:585-598 [9] [21] In the 2014 book, "The Body Keeps The Score," Bessel van der Kolk offers an interesting view arguing that all trauma is harmful, and that trauma is either buried or accepted. [15] Other authors maintain that only "subjective trauma" causes problems. [22] Whichever view you take, there does not seem to be any genetic factor for this disorder, since anyone can, with the right circumstances, develop dissociative identity disorder. [7] Dissociative identity disorder results from a combination of factors that come together to create the perfect storm with "traumatic neglect" experienced within more than one "childhood developmental stage". [23]:208-211 [8]

Cause of dissociative identity disorder includes two phases
Phase I: events occurring in the first year of life
The infant is consistently overwhelmed.
Adults in the infants life do not sooth the infant.
Phase II: age 1 to age 7
The child is consistently overwhelmed, again in this stage.
Adults in the child's life do not sooth the child - again in this stage.
A secure attachment has not been formed with any adult.
Trauma memories are not being processed.
Eventually the buildup of trauma memories results in Structural Dissociation of the child's personality.
The child now has a distinct and less than distinct states making up their personalityEvery individual has a personality that is composed of many diverse, fragmentary and generally illusory images of [[Personality|self]]. (see multiples) <ref name=Noricks2011/>The DSM-IV uses the term identity in its definition of dissociation. (see identity) <ref name=Dell2009/>{{Rp|127}}. Their personality is now damaged and no longer normal.
Integration of what were normal ego"the notion of a being who both thinks and acts". Feeling is also a characteristics of the ego. (van der Hart & Horst (1989){{Rp|2}}) Ego states is a term sometimes used to refer to several different identities within a person with Dissociative Identity Disorder, i.e., several different dissociative parts of the personality, each with his/her own sense of "me". states is no longer possible.
The synonym TRAUMA sums up DID etiologyThe study of the cause of a disorder or disease. In the case of dissociative identity disorder, early and severe childhood trauma, especially abuse is considered to be the cause. <ref name=ISSTD.org/>
  • T rauma resulting in Structural Dissociation
  • R est between trauma events is less than required to process trauma memory
  • A ge neglected & traumatized as an infant, and then again between age 1 and 7
  • U nprocessed trauma memories overwhelm a child resulting in Structural Dissociation
  • M otion exists between the mind and the brainThe brain is a approximately a 1300-gram organ containing 100-billion neurons. It is the control center of the central nervous system. The mind and brain are not the same thing. (see mind) The mind emerges out of interactions between the brain and relationships during the earliest years of childhood. Different child-parent attachment relationships form differing physiological responses, patterns for interpersonal relationship and how an individual views the world. <ref name=Siegel2012/>{{Rp|9}} (see attachment), but it's inadequate to process trauma memory
  • A ttachment - inability to form a secure attachment with a primary caregiver

Treatment

Medication does not aid in the treatment of dissociative identity disorder. [24] The only treatment that has ever been proven to result in full unification of any individual with dissociative identity disorder is talk therapy. A therapist (or another) provides support and encouragement while the afflicted individual literally changes the way their mind and brain work. This is a powerful statement, but the work being done is what should have occurred naturally in the first years of life, but it was prevented by outside forces. The brain and mind will keep attempting the process, and once the work is brought to conscious thought enough, the natural process moves forward, but it does take years of hard work. The individual states must reduce fear between themselves enough that there can be acceptance of all self states. Communication will follow, and finally trauma memory processing, reduction of symptoms, followed by a return to the natural way the mind and brain were meant to be. [25] [26]

IntegrationIntegration (state of unification) occurs in the minds of all individuals and is a process rather than an end product. "If integration is impaired, the result is chaos, rigidity, or both. Chaos and rigidity can then be seen as the red flags of blocked integration and impaired development of the mind." <ref name=Siegel2012/>{{Rp|9}} The natural process of the mind is to link differential parts (distinct modes of information processing) into a functional and unified self. No child has unified personality when born, in fact, they need years of sufficient nurturing for the parts of their personality to integrate. <ref name=Siegel2012/>{{Rp|394}} "Integration is more like making a fruit salad than like making a smoothie: It requires that elements retain their individual uniqueness while simultaneously linking to other components of the system. The key is balance of differentiation and linkage." <ref name=Siegel2012/>{{Rp|199}} Integration is the normal process that occurs in early childhood, but if interrupted by trauma, the child may not be able to integrate. <ref name=Howell2011/>{{Rp|143}}

This work is done between the states as was just explained in the above paragraph. ToleranceIn substance and/or drug use tolerance refers to a decreased response to a drug dose that occurs with continued use. Increased doses are needed to produce the same effects. One of the criteria for the dependence syndrome. <ref name=WHOdrugterms/>{{Rp|62}} between states is primary, followed by acceptance, and fear reduction, with overlapping episodes of trauma memory processing. The process of integration leads to a unified personality, which is a normal personality construction void of distinct and less than distinct states, which in no way means that any state is destroyed, but they will no longer be dissociated and isolated due to dissociative boundaries. The individual will finally be able to process trauma memories and will now fail to suffer from the symptoms of Structural Dissociation. Upon unification all states still exist and communicate with each other, but in a smooth way that causes no harm. The states will be trauma free and free of the disease that was inflicted upon them. [2] During most of the work will overlap. [17]:599-652 [10] [27] [28] See our detailed section on integration for more.

Prognosis

When untreated there is chronic and recurrent symptoms varying overtime including long-lasting effects. because the brain and mind will keep going around in circles unable to find resolution until the matter is brought to consciousness to be worked on. [29] [17]:637-652 At least four-years of psychotherapy are usually needed for adults (less for children) to allow time for trauma memory processing, elimination of dissociative boundaries and to obtain a unified sense of self. [1] [17]:637-652 Estimates of patients that do obtain full integration range from 16.7% to 33%. [30]

History

This graph shows how distinct states differ from less than distinct states by measuring the activity between them, which shows how each state is able to share memory and other aspects of itself with other states. A distinct state exhibits far greater isolation than a less than distinct state. When viewing the less than distinct states the observing selves show the least isolation of all states, and the experiencing states are somewhere between the observing and the distinct states. Read this important study here.

Paul F. Dell led a drive to understand posttraumatic stress disorder, the Dissociative Disorders and dissociation in his multi-authored, 864 page book titled: Dissociation and the Dissociative Disorders: DSM-V and Beyond. The massive book was an attempt made in 2009 to bring to the forefront the main ideas of the research community, [31] [7] but there was little agreement at that time and the book strongly reflected that fact. [22] More recently, Ellert R.S. Nijenhuis and Onno van der Hart have led the field with an unearthing of knowledge that was influenced by the French genius, Pierre Marie Félix Janet. [23] [32] Janet, amid an onslaught of naysayers including Sigmund Freud, determined that the minds ability to dissociate, was influenced by what he called "dissociative determinations," which is referred to today as subjective trauma. [32] Janet insisted that the mind is made up of a network of neurons that when healthy, work together in harmony, but when "infected" by trauma memory, the mind has no choice but to react and interact with stimulus. [25] [32] Janet pointed out that while the process had purpose in human evolution, it is counter-productive in "modern man". [7] [33] Janet's work was stifled by influential researchers that took another path after Janet died. [32] There was a media circus in response to movies, books and other public information sharing including "Sybil," "Three Faces of Eve," and the Billy Milligan story. The symptoms and presentation were mixed portrayals of dissociative identity disorder, and other specified dissociative disorder and other comorbid disorders and somatic disorders. All this confusion created a Frankenstein effect that was more fantasy than reality. [23]

Rational took over when Ellert R. S. Nijenhuis and Onno van der Hart dug into the original writings of Janet and brought them to light. They demanded that Janet's work be heard and understood as they worked together to process the historic information. Later, Kathy Steele joined the two men and the three researching clinicians published the landmark book: The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. [6] There were earlier journal articles on this subject by the three authors, but it was the book that fully introduced the concept of what today is called Structural Dissociation of the Personality. [17]:3-26 Now in 2014 fMRI scans exist that support the continuing efforts by Ellert R. S. Nijenhuis and Onno van der Hart. Most neurologists that write about dissociative identity disorder share similar views, even if they don't use the same terminology. [34]

Mention in the DSM

There was nothing about "multiple personalities" in the DSM-I, but the DSM-II did mention the term as a symptom of neurosisNeurosis is an emotional disorder. Neurotic refers to a person displaying a symptom of emotional distress, which could range from anxiety, panic attacks depression, and lying, to promiscuity. <ref name=Hook2004/>{{Rp|97}} This historical term referred to a very large group of conditions, which were later divided between Mood Disorders, Dissociative Disorders, Anxiety Disorders, Somatization Disorder and Personality Disorder. Neurosis was removed from the DSM completely because it suggested a "cause" common to the categories under that term, and to "reduce confusion" <ref name=Decker2013/>{{Rp|272}}. The DSM-III was the first time that "multiple personality disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder, which was from 1980-1994. The International Classification of Diseases,(ICD) still uses this label, <ref name=ICD10/> even though the ICD-11 is expected to change it. The term is misleading. No one can have more than one personality, nor is the disorder a personality disorder. {{See also| Multiple Personality Disorder}}" was listed in a DSM as a diagnosis of its own. The name was misleading however, since this mental disorderThe DSM-5 psychiatric manual defines this as "a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."<ref name=DSM5Deskref/>{{Rp|20}} has never been listed as a Personality Disorder and has nothing significant in common with Personality Disorders.

Diagnostic manual

Diagnostic manuals like the DSM and ICD are not meant to be used to understand any mental disorder. [20]:19 Their intent is to give the minimum criteria needed to diagnose a disorder. The criteria listed here is paraphrased.

DSM5.jpg

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), was released to the public May 27, 2013. Pages 291-298 of the DSM-5 give a written account that follows an older, more or less general consensus to what dissociative identity disorder is, but it's not up to par with the superior criteria that is presented in the DSM-5. [20]:291-298 [2]:243-470 [14] [35] [11] [36] Although what a distinct state is and is not, has been known, and then lost throughout history, the information is accepted well enough today to be presented with full confidence. [21] [10] [2]

DSM-5 was last updated May 2013
  • A. Two distinct states switch with disruption in identity. [20]:291-298
  • B. True amnesia, not dissociative amnesia is present between two distinct states. [20]:298-302
  • C. The individual is significantly impaired due to the presenting symptoms.
  • D. This is not a "temporary state" created purposefully by cultural practice.
  • E. The symptoms are not attributed to anything else.

The main DSM-5 criteria used to diagnose dissociative identity disorder pinpoints the very characteristic that separates it from all other mental disorders, by exposing this disorder as the only one with two or more distinct states, and thus the only disorder where true amnesia takes place between states. [6]:73-88 The amnesia criteria helps to distinguish distinct states from less than distinct states. [2]:5-28

In the DSM-5 section: Somatic Symptoms and Related Disorders, and under conversion"The development of symbolic physical symptoms and distortions involving the voluntary muscles or special sense organs; not under voluntary control and not explained by any physical disorder." Sadock (2008). Functional Neurological Symptom Disorder is the new name for Conversion Disorder in the DSM-5 manual, and is part of the Somatic Symptom and Other Related Disorders category. Somatization Disorder was removed during the changes, but is represented in this category. <ref name=DSM5changes/>{{Rp|11}}Conversion symptoms are most common in conversion disorder, but also seen in a variety of mental disorders." <ref name=Sadock2008/>{{Rp|23}}"Conversion disorders" is the ICD-10 category includes somatoform dissociation within dissociative disorders of movement and sensation.<ref name=Nijenhuis2001/> {{Rp|9}}{{See also| Somatoform Disorders}} disorder (functional neurological symptom disorder) there is a note that dissociative symptoms are common in individuals with conversion disorder, and if both conversion disorder and a Dissociative Disorder are present, then both diagnosis should be made separately. [20]:321

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