Dissociative Identity Disorder

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PierreJanet.jpg

A diagnosis of dissociative identity disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder in the DSM manual 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 and well known that 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 has amnesia due to switching between different personality states (also known as alters). <ref name=Dell2009/>{{Rp|319-321}} {{See also| Dissociative Identity Disorder}} (DIDDissociative identity disorder is a disorder of mental states, where a individual has amnesia due to switching between different personality states (also known as alters). <ref name=Dell2009/>{{Rp|319-321}} {{See also| Dissociative Identity Disorder}})is accomplished when all four criteria listed in the DSM-5 present with enough influence to be assured an accurate of diagnosis.(Nijenhuis, 2006) It's unlikely that the layman understands the DSM-5 criteria well enough to diagnose, and the same is true for mental health professionals who have not been trained in the necessary intricacies.(Dell, 2009, p. 383-402)(Obsuth, 2014)

Paul F. Dell has led a drive to separate the complex dissociative disorders from other disorders. His multi-authored, 800 page book titled: DissociationThis explanation refers to pathological dissociation only; which is dissociation which is a symptom of or causes a mental health disorder. For normative dissociation see Dissociation page. Dissociation 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. True or pathological dissociation requires an experiencing Self. <ref name=Dell2009/>{{Rp|233-234}} and the Dissociative Disorders: 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}}-V and Beyond, was an attempt made in 2009 to bring to the forefront the main ideas of the research community. There was little agreement at that time and the book strongly reflects this. More recently Ellert R.S. Nijenhuis has led the field with his unearthing of knowledge that was not only influenced by the French genius, Pierre Marie Félix Janet, but was actually understood to an extent that no one today can grasp.(Chu, 2011)(Obsuth, 2014)

Janet identified the minds ability or disability, depending on your point of view, to react to trauma by moving a trauma memory to a "holding tank." While this allowed the individual to go on with daily life, it also caused distress revealed as what we call symptoms. Janet understood that the mind was made up of many parts, and one of them is what is called the personality. The personality is a network of neurons that work together in harmony when healthy, but when infected by a trauma memory in the holding tank, the mind has no choice but to react and interact with the problem. This seems counter productive since the mind is trying to protect itself by containing the trauma memory,and it is, but not without consequences.

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Janet knew that the goal was to figure out just what those consequences would be, and he did achieve that in his lifetime, but this important knowledge was stifled by later researchers such as Dr. Cornelia Wilbur who was responsible for the story of "Sybil," who probably had other specified dissociative disorder. (Obsuth, 2014)(Kluft) Prior to this was the story of the "Three Faces of Eve," who also probably had other specified dissociative disorder (Obsuth, 2014) then came forth Billy Milligan's story. The symptoms and presentation were mixed portrayals of dissociative identity disorder, and other specified dissociative disorder, as the researchers of that era, and of course the media, confused the two disorders creating a Frankenstein effect that was more fantasy than reality.(Chu, 2011)(DSM5, 2013)(Nijenhuis, 2006)(Obsuth, 2014)Janet's work became lost in the popular media circus and there it stayed, for the most part, until Ellert R. J. Nijenhuis, as part of a research study he was doing, dug into the original writing of Janet.(Obsuth, 2014) Nijenhuis is a brilliant man himself, and he was able to make sense of what he found.(Obsuth, 2014) In fact, he did more than that. He demanded that Janet's work be heard. Onno van der Hart, another brilliant man, aided in the work and together they processed the information that was found. (Obsuth, 2014)Later Kathy Steele joined them and the three researching clinicians published the landmark book: The Haunted SelfThe DSM-IV uses the term identity in its definition of dissociation. (see identity) <ref name=Dell2009/>{{Rp|127}}: Structural DissociationStructural dissociation (SD) is one of the three accepted models for the etiology of dissociative identity disorder. <ref name=HauntedSelf/> <ref name=Dell2009/>{{Rp|158-165}} {{See also| Structural dissociation}}Structural dissociation of the personality is a theory that describes the effect of trauma on the personality. It applies to PTSD, complex PTSD, other specified dissociative disorder and dissociative identity disorder. and the Treatment of Chronic Traumatization (Nijenhuis, 2006). There were earlier journal articles by the three authors, but it was this book that fully introduced the concept of what today is called structural dissociation of the personality.(Nijenhuis, 2006)(Dell, 2009, p. 3-26)(Obsuth, 2014)

Understanding the DSM-5 (Diagnostic and Statistical Manual of Mental DisordersPublished 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}}) criteria

The American Psychiatric AssociationThe APA is a scientific and professional organization that represents psychiatrists in the United States. The American Psychiatric Association publishes the DSM. <ref name=DSMIV/> <ref name=DSM5/> Commonly confused with the American Psychological Association. (APA) publishes the Diagnostic and Statistical Manual of Mental Disorders DSM. The most current version is the DSM-5 which came out May 27, 2013. This references lists the criteria for dissociative identity disorder. The two main criteria are as follows.

• Disruption of identity characterized by two or more distinct personality parts.

AmnesiaMemory loss. {{See also| amnesia}} between parts of the personality.

Amnesia, as used by the work committee responsible for the DSM-5 criteria leaves the term undefined. However, amnesia is so misunderstood that it has literally fed the popular media version of dissociative identity disorder.(Chu, 2011)(Dell, 2009, p. 383-402)(Siegel, 2012) The second criteria which is the disruption of identity characterized by two or more distinct personality parts is easier to identify, but there is confusion about which parts need to be identified.(Chu, 2011)(Dell, 2009, p. 383-402)(Siegel, 2012)(Obsuth, 2014) Let's use an example to explain this. Annabelle is 25 years old and her 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.{{cn}} is Dr. Getsitright. Annabelle presents to him with obvious amnesia and distinct parts of her personality, but what does that mean? Let's look closely.


Annabelle knocks on Dr. Getsitright's door, a mental health professionalThe various mental health professionals provide services basked on their training and area of expertise. whom she has never met before. She has come to him because she has an eating disorder. He answers the door and invites Annabelle to have a seat in his small office. She looks confused as if she does not know where she is. There are many things in the office including books, a nice desk, a few chairs of different variety and some nick-knacks meant to attract various ages of clients. Annabelle's eyes go right to the children's books. Dr. Getsitright has a magnificent display of them. There are psychology books of course, but also books on knitting, crafts, cooking, home projects and children's books. Dr. Getsitright notices Annabelle's interest in the books and he asks if she would like to borrow one. She dismisses his question and changes the subject. "I would like to talk about what's wrong with me, so let's get right to work," she says curtly. Dr. Getsitright is confused for a moment, but then he notices a shift in her presence. Annabelle appears disturbed by the doctor's waste of her time. Now she says, in a distinctly different tone than she has used yet while in the office, "Dr. Getsitright, how am I suppose to get any work done if we dilly dally among the books all day?" Dr. Getsitright asks "Are you Annabelle Lector, the woman I am suppose to meet with today at noon?" Annabelle answers in a quiet voice that is both polite and stutters, "Why of course I am. You and I already introduced ourselves. Why ever would you ask such a foolish question?"


Let's take a look at this example. The first part of Annabelle that comes into the office is attracted by the books. She is an obvious part of the personality that does not deal with daily life, but she does like books for sure. Although an ANPAn alter who often acts as the host, does not hold trauma memories (has amnesia for trauma). Dissociative identity disorder is the only mental disorder where an individual can have two or more ANP. <ref name=HauntedSelf/> A term used for the part that often acts as the host alter in individuals with dissociative identity disorder according to the model of structural dissociation. {{See also| structural dissociation}} can be attracted by the books, but this part was attracted by the children's book and is probably what is referred to as an emotional partAn alter (or identity fragment) whose main job is to hold unintegrated trauma memory. A term used in structural dissociation. <ref name=HauntedSelf/>{{Rp|38-39}} of the personality or EPAn alter (or identity fragment) whose main job is to hold unintegrated trauma memory. A term used in structural dissociation. <ref name=HauntedSelf/>{{Rp|38-39}}. There are two very distinct types a person with dissociative identity disorder will have. Notice that when the mental health professional asks if Annabelle would like to borrow a book, she switches to another part of the 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}}. This part is called the apparently normal part or ANP and it attends to daily life. To diagnosis dissociative identity disorder, according to the DSM-5, there needs to be a distinct and disturbing loss of memory between two parts. These 2 parts are the ANP. Let's look at more of the visit and see if we can identify another ANP. Look at the part that is upset that the doctor is seemingly wasting her time. That would be an ANP who is attending to daily life. The diagnosis would be dissociative identity disorder since the only mental disorders known to have more than one ANP is dissociative identity disorder.

The first point of this vignette was to show that amnesia can be observed between parts of the personality. (Chu, 2011)(Siegel, 2012)(van der Hart, 2006)(Obsuth, 2014) Annabelle, in her short time in Dr. Getsitright's office is displaying amnesia in all five ways that are possible. Amnesia between the ANP, which again are the parts that go about the daily tasks in life, is seen when she does not remember anything between the introduction between herself and Dr. Getsitright. The next form of amnesia that could have been observed by the mental health professional in this vignette, is when Annabelle does not realize that she is the one that was interested in the children's books. All she heard was Dr. Getsitright asking if she wanted to borrow one. This is amnesia between the EP who was looking at the children's books and the ANP that switched with her as she heard Dr. Getsitright speak. The next two forms of amnesia are so closely related that it's hard to distinguish one from the other, but pay close attention and you will see it.(Siegel, 2012) When Annabelle walks into the office an astute observer would be able to tell that she does not remember ever knocking on the door, but it's obvious, if trained, to she did know where she was going and had to assume she has arrived. This is common with ANP.(van der Hart, 2006)(Obsuth, 2014) They disregard the fact that they have no idea how they get from one place to another. This is their job, and they do it well. This combines two forms of amnesia because it identifies what is known as dissociative amnesia as well as amnesia between what are probably two ANP. (Obsuth, 2014)(Nijenhuis, 2006) One had the job of getting to the appointment and the other had the job of talking to the mental health professional, at least at some points during the visit.

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Now let's look at how "disruption of identity characterized by two or more distinct personality parts" is observed in our example. Here is where astute observation is imperative or the wrong diagnosis can be made. (Chu, 2011) According to structural dissociationStructural dissociation (SD) is one of the three accepted models for the etiology of dissociative identity disorder. <ref name=HauntedSelf/> <ref name=Dell2009/>{{Rp|158-165}} {{See also| Structural dissociation}}Structural dissociation of the personality is a theory that describes the effect of trauma on the personality. It applies to PTSD, complex PTSD, other specified dissociative disorder and dissociative identity disorder., someone with dissociative identity disorder has two or more ANP and two or more EP, while the other complex dissociative disorder has only one ANP, but also two more more EP.(Nijenhuis, 2006) If only switches from ANP to EP or EP to ANP are observed, then the diagnosis would be other specified dissociative disorder (OSDD). If switches from ANP to ANP are observed then the diagnosis would be dissociative identity disorder. Anabelle shows both types of 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 alters, which is a <ref name=Dell2009/>{{Rp|228}} criteria for a diagnosis of Dissociative Identity Disorder in the DSM. {{See also| Dissociation}} and Dr. Getsitright would be correct in diagnosing her with dissociative identity disorder. (Chu, 2011)(Siegel, 2012)(Obsuth, 2014)See also DSM.

Understanding the difference between DID, OSDD and dissociative PTSD

There is a great deal of confusion centered around the differences between secondary structural dissociation (OSDD and complex PTSD) and dissociative identity disorder. (Chu, 2011)(Dell, 2009, p. 155-170) This section will help readers identify the difference in theory, on paper, in therapy and in life in general.

Anabelle walks into a group therapy session, followed by Mortimer, Peal and Dr. Getsitright. This is the first session for all of them. They mingle around the coffee and cookies until Dr. Getsitright calls them to take their seats. Pearl and Mortimer immediately take their seats, but Annabelle is still at the cookie table. Dr. Getsitright goes over to her and as he starts to speak she startles. He immediately knows what is going on. He sees the pattern. ANP switch to EP who is startled and switches to an ANP, who greets Dr. Getsitright as if she has no idea what is going on and she politely takes her seat with the others. Dr. Getsitright is curious so he wants to make sure his observation is correct, so he sets up a test. He brings a tray of cookies and sets it on his chair. The group has their chairs in a small circle. He watches Anabelle carefully as the rattles on about this and that. Then he takes the cookies and tosses them all into the trash can and he watches Anabelle's reaction. Sure enough he sees what he is looking for. She startles. Why on earth would a grown woman startle because cookies are tossed into the trash? Well it's very unlikely one would, but an EP on the other hand could become upset when seeing the cookies she/he was just eating tossed in the trash. Dr. Get's it right observes what happens as he begins to call the meeting to order. Just as the thought Anabelle adjusts her posture and appears to have switched to an ANP. (Chu, 2011)(Dell, 2009, p. 155-170)(van der Hart, 2006)

How can Dr. Getsitright be so sure that Anabelle is switching from an ANP or an EP, or even switching for that matter? It does take a training. Here is what he is looking for. An EP typically acts young, frightened and is controlled by emotions. They can't help but respond emotionally.(Chu, 2011)(Dell, 2009, p. 155-170)(van der Hart, 2006) This is the definition of an EP - it's an emotional part of the personality.(van der Hart, 2006) The ANP, although it has a normal range of emotions, cannot help but respond to daily life actions.(van der Hart, 2006) Cookies have many emotions tied to them. They are used for rewards or to punish. They are part of childhood, whether a child gets them or not and they are not something an ANP would care about. We have observed Anabelle switching from and ANP to an EP, so she could have secondary structural dissociation which encompass dissociative PTSD, OSDD, dissociative borderline personality disorder (BPD).(Chu, 2011)(Dell, 2009, p. 155-170)(van der Hart, 2006) We can quickly rule out BPD because that does not fit the pattern at all, (van der Hart, 2006) but OSDD and dissociative PTSD do. (van der Hart, 2006) First let's rule out dissociative PTSD. We can do that in the following ways, but the easiest is to see if Anabelle has DID. (Chu, 2011)(Dell, 2009, p. 155-170)(van der Hart, 2006)

ANP's define dissociative identity disorder and leave no doubt as to the diagnosis.(Chu, 2011)(Dell, 2009, p. 239-258)(van der Hart, 2006) As we have explained before what we are looking for is a switch from ANP to another ANP.(Dell, 2009, p. 239-258)(van der Hart, 2006) It's important to understand the ANP's in dissociative identity disorder because they are very different from the ANP's in secondary and primary structural dissociation. (Dell, 2009, p. 239-258)(van der Hart, 2006) An ANP in dissociative identity disorder is unable to acknowledge other dissociative parts of the system. (Chu, 2011)(Dell, 2009, p. 239-258)(van der Hart, 2006) While this can happen to a limited extent in secondary structural dissociation, it's the key component of tertiary structural dissociation (DID).(Chu, 2011)(Dell, 2009, p. 239-258)(van der Hart, 2006)

Here is the pattern. Dissociative identity disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder in the DSM manual 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 and well known that 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 has amnesia due to switching between different personality states (also known as alters). <ref name=Dell2009/>{{Rp|319-321}} {{See also| Dissociative Identity Disorder}} = ANP + ANP = intense phobia of other parts of the personality = amnesiaMemory loss. {{See also| amnesia}} between the ANP's due to the intense phobiaMost of the time, the host alters denies existence of other alters, rather than those other alters hiding from the host. <ref name=HauntedSelf/>{{Rp|80}} Alters will avoid each other and their painful memories and experiences, or they tend to have strong conflicts with each other. <ref name=Boon2011/>{{Rp|31}}.(Dell, 2009, p. 239-258) The ANP's in dissociative identity disorder literally cannot stand to be in the presence of other parts of the personality.(Chu, 2011)(Dell, 2009, p. 239-258)(van der Hart, 2006) Of course they have no idea they are so phobic, but they are.(Dell, 2009, p. 239-258)(van der Hart, 2006) The ANP's will not be able to acknowledge a loss of time due to this phobia.(Dell, 2009, p. 239-258)(van der Hart, 2006) To acknowledge it is to acknowledge other parts exist. (Dell, 2009, p. 239-258)(van der Hart, 2006) Instead they will blindly accept whatever environment they show up at.(van der Hart, 2006) They become use to doing this from very early in life and the pattern continues.(Chu, 2011)(van der Hart, 2006) Of course this will change as 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. (see multiple) <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 and disorganized attachment, the child may not be able to integrate, resulting in a dissociative disorder. <ref name=Howell2011/>{{Rp|143}} As an adult, when therapy is sought out, an individual who has unresolved trauma and lacks integration, can finally get the help needed to process the trauma memories, which needs to be done prior, and to finally [integrate the alters making up the ersonality into one unified self. <ref name=Noricks2011/>{{Rp|141-144}} continues and the dissociative boundaryA dissociative boundary. Interidentity autobiographical amnesia must be present, and obvious, in at least two alters to meet the DSM criteria for dissociative identity disorder. It is the dissociative boundary that separates alters resulting in a lack of communication. <ref name=Spiegel2011/> <ref name=DSMIV/> <ref name=DSM5Deskref/> {{See also | Amnesia}} around the ANP become more aware, but that will be discussed in the section on this page the explores neurochemistry and neurobiology.(Chu, 2011)(van der Hart, 2006)

Symptoms

Severity of symptoms in those with dissociative identity disorder differs ranging from an individual that acts and feels normal, or even highly effective to those that are severely impaired. The main symptom, dissociation, reduces distress and acts as a coping mechanism, but at the same time causes its own mental and physical impairments. Individuals with this disorder may experience all the five known types of amnesia: generalized, systematized, localized, continuous, selective.(Chu, 2011)(Siegel, 2012)(van der Hart, 2006) Dissociation can result in stored memories, skills, affects and other knowledge compartmentalized into distinct states. (Dell, 2009, p. 225-238)Traumatic unprocessed memories are often reveled as nightmares, flashbacks, and 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." Kaplan and 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}} symptoms. (Brand, 2010)

Etiology

Dissociative identity disorder is thought to occur when a child is unable to develop a unified sense of self. (ISSTD, 2011, p. 133) There are three etiological models accepted by the International Society for the Study of Trauma and Dissociation (ISSTD), and all three report that dissociative identity disorder is the result of 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}}. (Dell, 2009, p. 93-106)Psychological trauma and dissociation are entwined closely. When early trauma is chronic and severe, it can result in dissociation and even change 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) structure. In addition, a combination of trauma and chronic emotional neglect in early childhood leads to attachmentThe communication of emotion between an infant and their primary caregiver(s) is essential to shaping the developing mind. "Emotion serves as a central organizing process within the brain. In this way, an individual's abilities to organize emotions - a product in part, of early attachment relationships directly shapes the ability of the mind to integrate experience and to adapt to future stressors." <ref name=Siegel/>{{Rp|9}} Interruption in the attachment pattern of young children with their caretaker(s) has been shown to be a primary precursor to Dissociative Disorder pathology. (see etiology) <ref name=Medscape/> <ref name=HauntedSelf/>{{Rp|85}} <ref name=Howell2011/>{{Rp|97}} difficulties which is prevalent among those with dissociative identity disorder.(Hazard, 2004)(Ross, 2011) Age is also a critical factor. (Chu, 2011)(Siegel, 2012)

"The age of the individual at the time of the abuse is a critical component due to the developmental processes that, under other circumstances, would normally occur at that time. In addition, the age at the beginning and the ending of the abuse is significant as it encompasses the sequence of developmental stages spanned by the maltreatment and should influence which developmental tasks are most disrupted. (Chu, 2011) Although there is no conclusive data in this area, it appears as if vulnerability to dissociation increases if the 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/> occurs at earlier developmental stages." (Gentile, 2013)

Etiology is best understood through the understanding of what is called structural dissociation of the personalty. (van der Hart, 2006) There are other ways, but none are as straight forward and easy to understand the basics. Let's look at an example since it is the best way to explain so that it can be understood. Anabelle was just born a few days ago and she has already suffocated, starved and has not felt the love and comfort of a caring parent. (Chu, 2011) She is vulnerable to all sorts of mental disorders due to this, (Siegel, 2012) but there is one item that is distinct to those with dissociative identity disorder and that is severe compartmentalization. It's this ability, or disability, depending on how you look at it, that keeps a child alive and sane. (Chu, 2011) Depending on what happens after the first days of life determines which 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 expectable 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}}, if any a child will get. (Siegel, 2012)(van der Hart, 2006) Let's take a look at Annabelle and how she develops dissociative identity disorder.

Annabelle lies in her crib and is alone with her thoughts. She is not comforted, she is not held, or played with. She is hungry, dirty and in pain. She is a neglected and abused newborn baby girl. Let's take a look in her head to see what's going on. There is no one to respond to her primitive needs, so what does that do to her mind? According to most experts, it causes what is known as disorganized attachment. (Chu, 2011)(Siegel, 2012) (van der hart, 2006) She is persistently hungry, and when and if she cries she is met with anger. She learns not to respond to the pain of hunger, (Siegel, 2012)(van der Hart, 2006) but what is going on in her head when she does this? She is learning a basic animal response. (Chu, 2011)(Siegel, 2012)(Nijenhuis, 2006) Hunger equals pain but not enough pain to endure the wrath of a caretakers anger. (Dell, 2009, p. 93-106)(Chu, 2011) The infant learns to ignore the pain of hunger by dissociating. (Chu, 2011)(Siegel, 2012)(Nijenhuis, 2006) Now instead of hunger equals pain, we have hunger equals dissociationThis explanation refers to pathological dissociation only; which is dissociation which is a symptom of or causes a mental health disorder. For normative dissociation see Dissociation page. Dissociation 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. True or pathological dissociation requires an experiencing Self. <ref name=Dell2009/>{{Rp|233-234}}. (Siegel, 2012) If this is the case, then what is going to happen when there are other types of pain. Experts believe the baby will dissociate in response, to one degree or another. (Chu, 2011)(Siegel, 2012) This is a learned behavior. (Dell, 2009, p. 93-106)(Chu, 2011)(Siegel, 2012) There is more going on in this infants head than her new learned ability to dissociate away pain. (Nijenhuis, 2006) She is also learning to comfort and sooth herself. (Chu, 2011)(Siegel, 2012) She only has herself, so that's where she turns. (Dell, 2009, p. 93-106) She listens inside for anything - anything at all. What she finds is subjective, so we won't go there.(Chu, 2011)(Siegel, 2012)(van der Hart, 2006)

Let's say Annabelle is now 6 weeks old and she is very thin, her bottom is covered in sores from diaper rash, and she is quiet and never cries. She sounds like an easy baby to take care of, but that's deceiving. Her needs have not been met so she is developing a mental disorder, but what type yet is still unknown.(Chu, 2011)(van der Hart, 2006) At 6 months old she is still in the same boat. She is a quiet and unhappy baby, but she is easy to take care of. (Dell, 2009, p. 93-106)(van der Hart, 2006) What's going on in her brain, as opposed to her mind? The brain needs nourishment and stimulation and she is getting little of either. (Siegel, 2012)(van der Hart, 2006)If it does not get something it will suffer. (Siegel, 2012) The mind is different. The mind can create it's own stimuli and it does in her case. (Siegel, 2012)(van der Hart, 2006) Her mind is actively stimulating her brain, and in fact it's doing it in excess to make up for the lack of internal stimulation. (Dell, 2009, p. 93-106)(Chu, 2011)(Siegel, 2012)(van der Hart, 2006) How is she doing this? She is talking to herself inside her head. She is creating the base that is needed for her to have a complex dissociative disorder. (Dell, 2009, p. 93-106)(Chu, 2011)(Siegel, 2012)(van der Hart, 2006)

There are only two kinds of complex dissociative disorders. In structural dissociation one is considered to be secondary structural dissociation and the other, which is dissociative identity disorder is the only mental disorder in the structural dissociation category of tertiary structural dissociation of the personalty. (Dell, 2009, p. 107-143)(van der Hart, 2006) Although this page is only about dissociative identity disorder, it's important to understand just how different secondary and tertiary structural dissociation are, so that will be addressed here in the section below. (Dell, 2009, p. 239-258)(van der Hart, 2006)

Etiology of other specified dissociative disorder and dissociative identity disorder

Here we continue our example of Annabelle, but will also add Mortimer. Annabelle gets dissociative identity disorder (DID) and Mortimer gets otherwise specified dissociative disorder (OSDD). Many people, due to their misunderstanding of the DSM and other printed material think these two disorders are similar, but they are far from that. (Dell, 2009, p. 367-372)(van der Hart, 2006) Let's take a look at the neurobiology of what's now going on with Annabelle. She has not suffered a trauma, per say, but she is set up due to neglect, so that if she does she is going to have a trauma 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}} that she cannot process. (Dell, 2009, p. 93-106)(Chu, 2011)(van der Hart, 2006) Let's leave this for a moment and take a look at Mortimer. He is 6 years old, and his childhood was just like Annabelle's. Neither have been beat, hurt physically or sexually abused, and so was the case for Mortimer until he turned 6 and half years old. On that way something horrible happened. While ice skating a thin section of ice broke and he fell into the frigid water. That's a trauma! Stranger got him out and offered him comfort and care, but as soon as he got home the usual pattern of neglect resumed. (Dell, 2009, p. 93-106)(Chu, 2011)(van der Hart, 2006) As a result Mortimer was unable to process his trauma memory. It's stuck in the primitive part of the mind that holds memories called implicit memory(Mental models, behaviors, images and emotions). Implicit memory involves parts of the brain that do not require conscious processing during encoding or retrieval." <ref name=Brown2003/>This form of memory is available in infancy and, when retrieved, it is not thought to carry an internal sensation that something is being recalled." <ref name=Siegel/>{{Rp|51}}Implicit memory is the first layer of encoded memory to be laid down. <ref name=SiegelCD/> The encoding literally shapes a child's architecture of the Self. <ref name=Siegel/>{{Rp|55}}At 18 months old, the hippocampus develops and this region of the brain matures and begins to integrate the building blocks of implicit memory together to form explicit memory.■ Earliest form of memory.■ Devoid of the subjective internal experience of "recalling," of self, or time.■ Involves mental models and "priming."■ Focal attention is not required for encoding.■ Mediated via brain circuits involved in the initial encoding and independent of the medial temporal lobe/hippocampus. <ref name=Siegel/>{{Rp|57}}. It can't get to where it needs to go, which is the part of the mind that turns memory into a narrative story without the horrible effects present in the primitive type of memory. (Chu, 2011)(van der Hart, 2006) This type of memory is called explicit memory. (Dell, 2009, p. 447-456) Mortimer still does not have otherwise specified dissociative disorder. This was a trauma, but it was not the type of trauma that needs to occur for OSDD to take hold. Mortimer could, at this point have what is commonly referred to as complex PTSD or that is in the DSM-5 as dissociative PTSD. At age 7 Mortimer's mother allows a child abuser to live with her and her son. It's important to note here that although it's almost always child abuse that causes OSDD there are other things that could happen at this point that will do the same thing to his mind. (van der Hart, 2006)

Example: Mortimer gets OSDD A man has moved into Mortimer's house and he has been beating and sexually abusing the boy and each time he does a new EP is created or an existing one takes further abuse. Keep in mind that this boy has the background that is needed for OSDD to occur from this. (Dell, 2009, p. 93-106)(van der Hart, 2006) The man keeps the boy locked in his room most of the time and he has nothing in there to occupy his time, so he turns to the inner worldInner reality in DID (Closed System). Each alter has its own inner reality, while at the same time there is a common inner reality where alters have a distinct, phantom appearance that is unchanging. <ref name=Dell2009/>{{Rp|301}} A closed system is a self care system that helps a child manage [[Attachment disorder|traumatic attachments]], and provide as a supplement to the scarce supplies available in an abused child's interpersonal environment. <ref name=Howell2011/>{{Rp|71}} of his mind. The EP establish themselves as part of his world and begin to become more and more distinct over time. Mortimer has OSDD. (van der Hart, 2006)

Example: Annabelle gets DID Anabelle has been locked in her room from the time she was able to walk. She has been beat, screamed at and unloved her entire life. She has suffered multiple traumas by the time she is even a year old. She has the background needed to have dissociative identity disorder, (Chu, 2011) but she does not have it yet. (Dell, 2009, p. 329-336)(van der Hart, 2006) She is however living most of her life in her mind and she is slowly creating a fantasy world which will aid her in obtaining DID. At age 2 the abuse intensifies. She already have several EP, which are the parts who have taken the abuse, but she only has one ANP and that's the criteria for OSDD and not dissociative identity disorder. To have DID she needs 2 or more ANP. At age 2.5 the police take her from her home and she is put into a wonderful foster home. There she is doing all sorts of daily life tasks, but this is all new to her. She develops new ANP for the jobs. Now she officially has DID. (Dell, 2009, p. 329-336)(Chu, 2011)(van der Hart, 2006)


As you can see the specifics of OSDD and DID are quite different, but still it's a struggle to get the lay person to understand the differences. It takes a mental health professional who has been trained to diagnosis the dissociative disorders to get a correct diagnosis.

The process of integration

Dissociation-And-The-Dissociative-Disorders-DSM-V-and-Beyond.JPG

Therapy is the primary treatment method and there are no medications to cure or manage it; the best results are obtained when trauma memories are "processed" (reassociated), allowing dissociative boundaries to abate and a unified sense of self to thrive, thereby reducing dissociative symptoms.

Prognosis

When untreated, there is chronic and recurrent symptoms varying over time including long-lasting effects such as suicidal tendencies, anxiety, and dissociative symptoms. [7]. Some individuals function at different times in their life with mild disturbance, while at different times they are severely impaired. [8]:14 At least two-years of psychotherapy are usually needed (for adults) to allow time for trauma memory processing, elimination of dissociative boundaries and for them to obtain a unified sense of self. [7] [9] Estimates of full integration range from 16.7% to 33%, [7]

Epidemiology

Tools designed to assess dissociative disorders, yield lifetime prevalence rates around 10% in the clinical population. [10] In children, rates among females and males are the same. In adults, more women are known to have dissociative identity disorder than men. Dissociative identity disorder is not rare; it is thought to occur in 1% to 3% of the worlds general population. [11]

History

Dissociative identity disorder was not included in the DSM-I, but in the DSM-II it was added 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}} and called "multiple personalities". It was not added as a disorder in itself until the DSM-III, and at that time it was referred to as multiple personality disorderPrior to the DSM-IV, <ref name=DSMIV/> <ref name=DSM5Deskref/> dissociative identity disorder was known as multiple personality disorder in the DSM manual 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 and well known that no one can have more than one personality, nor is the disorder a personality disorder. {{See also| Multiple Personality Disorder}}. A lot of myths and misinformation surround this disorder, and popular shows such as SybilSybil is a biography describing the life of a woman with dissociative identity disorder, published as a book in 1973 and released as a TV movie in 1976."It is often the first association that people have when they hear the words MPD or DID. Despite the Hollywood blitz associated with this disorder, however, the diagnosis appears to have begun in the last 1800s with Pierre Janet, a French psychiatrist, and William James, a student of philosophy and psychology." <ref name=Haddock2001/>{{Rp|12-13}} "Sybil" included descriptions of the severe abuse and sexual abuse she suffered during her childhood, and the help she received from her psychiatrist, Dr. Wilbur. <ref name=Schreiber1973/>Nearly 40 years later, after the death of "Sybil", a journalist published the heavily marketed book "Sybil Exposed" claiming Sybil did not have DID, but legal action forced the publishers of Sybil Exposed to remove a false statement on the dust jacket and provided additional evidence of false and fabricated statements in Sybil Exposed.<ref name=Suraci2011/> Coons (2013) later studied the original evidence and stated "the story of Sybil is true, not fraudulent or fiction". <ref name=Coons2013/> {{See also| History of DID}}, Three Faces of Eve and United States of Tara have perpetuated myths.

[12][13][14]

Related project

For more information see our other project site on dissociative identity disorder.

References

  1. ^ Brand, B.; Richard J. Loewenstein, (2010). Dissociative disorders: An overview of assessment, phenomenology, and treatment. Psychiatric Times.
  2. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am Chu, James A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders. Hoboken, N.J.:John Wiley & Sons.ISBN 0470768746.
  3. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj Dell, P. (2009). Dissociation and the dissociative disorders: DSM-V and beyond. London:Routledge.ISBN 0415957850.
  4. ^ Gentile, JP; Dillon, KS; Gillig, PM (2013). Psychotherapy and Pharmacotherapy for Patients with Dissociative Identity Disorder.. Innovations in clinical neuroscience, volume 10, issue 2, 2013 Feb, page 22-29.
  5. ^ Ross, Colin A.; Ness, Laura. Symptom Patterns in Dissociative Identity Disorder Patients and the General Population. Journal of Trauma & Dissociation, volume 11, issue 4, 7 October 2010, page 458–468. (doi:10.1080/15299732.2010.495939)
  6. ^ a b c d e f g h i j k l m n o p q r s t u v w Siegel, Daniel (2012). The Developing Mind, Second Edition: How Relationships and the Brain Interact to Shape Who We Are. Guilford press.ISBN 13: 978-1462503902.
  7. ^ a b c Brand, B.; Classen CC, McNary SW, Zaveri P. (2009). A review of dissociative disorders treatment studies. J Nerv MentDis., volume 197, issue 9, page 646-54. (doi:10.1097/NMD.0b013e3181b3afaa)
  8. ^ Shusta-Hochberg, Shielagh R.. Therapeutic Hazards of Treating Child Alters as Real Children in Dissociative Identity Disorder. Journal of Trauma & Dissociation, volume 5, issue 1, 28 January 2004, page 13–27. (doi:10.1300/J229v05n01_02)
  9. ^ Bethany L. Brand PhD (2012): What We Know and What We Need to Learn About the Treatment of Dissociative Disorders, Journal of Trauma & Dissociation, 13:4, 387-396 To link to this article: http://dx.doi.org/10.1080/15299732.2012.672550
  10. ^ Sar, Vedat. Epidemiology of Dissociative Disorders: An Overview. Epidemiology Research International, volume 2011, 1 January 2011, page 1–8. (doi:10.1155/2011/404538)
  11. ^ International Society for the Study of Trauma and Dissociation. Guidelines for Treating Dissociative Identity Disorder in Adults, Third Revision. Journal of Trauma & Dissociation, volume 12, issue 2, 28 February 2011, page 115–187. (doi:10.1080/15299732.2011.537247)
  12. ^ DSM5, APA (2013). Diagnostic and Statistical Manual of Mental Disorders. ISBN 13: 978-0890425558.
  13. ^ Nijenhuis, Ellert (2006). The Haunted Self. Norton.ISBN 13: 978-0393704013.
  14. ^ Obsuth, Ingrid; Hennighausen, Laura E. Brumariu and Karlen Lyons-Ruth (2014). Disorganized Behavior in Adolescent–Parent Interaction: Relations to Attachment State of Mind, Partner Abuse, and Psychopathology. Child Development, volume 85, issue 1. (doi:10.1111/cdev.12113)