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 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}} (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}}) is, without a doubt the most historically misunderstood and fascinating mental health categories. The reasons for this are complicated because genius, Pierre Marie Félix Janet already understood it quite well clear back in the 1800's. So what happened that confused those of us that are not as gifted. I would have to give credit to four groups of people, abusers, media, researchers and even the people with the disorder. Dissociative identity disorder is not some strange phenomenon that is difficult to comprehend. It is simply the result of a highly and early traumatized mind and 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).

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}} is given when two or more distinct, highly dissociated states present that literally have no idea the other state exists. While this could be confused with other specified dissociative disorder (OSDD) it at least gets us in the right playing field. There are two closely related mental disorders, which on paper are easy to identify. Dissociative identity disorder has two or apparently normal parts (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}})and OSDD has just one.

A trauma specialist should have adequate knowledge so he can distinguish when an individual presents with two apparently normal parts (ANP), who do not know each other exists or one ANP and 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}} (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}}) that does not acknowledge what is often called a shell in OSDD. Things get confusing when the lay person is trying to figure out what is meant by amnesiaMemory loss. {{See also| amnesia}}, because both the individual with OSDD and DID will have it. Even those with posttraumatic-stress disorder (PSTD) often do not remember the event(s) that are related to their disorder. In dissociative identity disorder the parts of the self are dramatically phobic of each other, and while this is true in OSDD, it's to a far lesser extent. This is how the two disorders can be distinguished. Knowing how to do that is the key to all this. So how can we figure out if someone has one or two ANP? That's the tricky part and hopefully by the time you read this entire page you will have a good idea of how it's done. If you are not up to date on the basics of structural dissociation 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}}, you can find those basics here. Let's start with an outstanding quote that will introduce the topic of age, trauma and child development.

"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. 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." [4]

Unified personality

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Before explaining what a personality that is not unified is, let's take a look at a unified personality, which of course is considered to be the norm. The process of unification is time consuming no matter what period of life it's attempted. It's slow, painstaking and involves a massive amount of time and energy to complete the process. [5] What we are attempting to understand is a complex set of biological and neurological pathways. [6] It's not a thing that you can remove from an individual and poke and prod like you could a heart, liver, lung and so on. It occupies the inner contents of the skull, as has already been said, but not as a solidified mass. [5] It's malleable, constantly in flux and is permeable to many things. In the case of a personality that has not unified, it was at some point, permeable to the chemical reactions that occur during a traumatic event. Although trauma can do many things to older children and adults, [7] we are talking about dissociative identity disorder here.

First, it's only logical that the initial trauma presents early in childhood, because if it's going to prevent the normal process of integrating the parts of the personality it needs to happen before all that work really gets underway. Most researchers believe that the initial trauma is the inability, for one reason or another, to keep an infant from harm. That's a vague statement, but it's probably an accurate one. [7] Even an infant older than two or three months has already began 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}}, and although research has not yet made this concept crystal clear, there are some expert researchers, like Paul F. Dell that have dipped their toes into this muddy water to try and show that for dissociative identity disorder to be the result of trauma it must occur early in infancy. Much later and the result can be other disorders such as OSDD, BPD, PTSD, or even antisocial personality disorder. [8] [9]

The apparently normal parts of the personalty

The apparently normal part of the personality (ANP) has unique characteristics that distinguish it from all others, including the fact that it is phobic of all other ANP. This can change over the course of time, but not without a great deal of work. If we took a 20 year old with dissociative identity disorder that has been in an abusive environment until she was 18, and she never had any type of therapy or help, we would find distinct ANP that were intensely phobic of each other. This type of thing is easy to identify and diagnose, but what if this same woman went to therapy at the age of eighteen, as soon as the left her childhood home? If it was proper therapy, then she would have begun the integration process and as a result the ANP would be much harder to distinguish from other parts of the personality, but still it can be done. Imagine you were this woman and you stopped your therapy at the age of twenty, then ten years later you had no idea you had dissociative identity disorder. That is a big red flag, but it's not waving because you of course don't know you have it even though you spend two years in treatment for it. Why?

Dissociative (amnesic) boundaries

The reason to the question above lies in the dissociative boundaries that capsule the ANP's. So what is a 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}}? I'm not going to pretend that's an easy question to answer, and the research I have read on it does not refer to it as a solid object, but at the same time they do not discount it either. [5] It seems this is one of those things we just don't know, but if we were going to venture an educated guess, based on current research by experts in this area, that guess would be that the dissociative boundaries are indeed of a solid nature. [6] When a boundary breaks down around other parts in the mind it's believed that first it becomes permeable rather than disintegrates all at once. If this is true, what this means for the person with dissociative identity disorder is they have to poke holes in that boundary until they can get rid of it and that is not an easy task, but we do know how that part is done and that takes us to the discussion of integration and therapy. [2][10]

The integration process

Psychological trauma and dissociation are closely entwined in a way that they cannot be separated. To have one is to have the other.

Defining dissociative identity disorder beyond the psychiatric manuals

Dissociative identity disorder is often separated into four categories:

  • Overt: There are distinct states where it is obvious to an individual that there is amnesia between the states. Only this category meets the DSM-5 criteria for dissociative identity disorder.
  • CovertCovert dissociative identity disorder gives Dissociative experiences scale scores that are lower than those with overt dissociative identity disorder. These individuals are skilled at hiding overt symptoms. The overwhelming majority of individuals with dissociative identity disorder have this version. <ref name=Dell2009/>{{Rp|424}}: DES scores are lower in those with covertCovert dissociative identity disorder gives Dissociative experiences scale scores that are lower than those with overt dissociative identity disorder. These individuals are skilled at hiding overt symptoms. The overwhelming majority of individuals with dissociative identity disorder have this version. <ref name=Dell2009/>{{Rp|424}}, as compared to overt dissociative identity disorder. The ANP's of these individuals deny and ignore their overt symptoms. The overwhelming majority of individuals with symptoms of this disorder have this version and they don't have any clue of their own pathology. (Dell, 2009, p. 424)
  • Subtle: This group of individuals has less frequent and severe dissociation when compared to individuals with either overt or covert versions. (Dell, 2009, p. 424)
  • Polyfragmented: Most individuals with the disorder have less than a dozen altersAltered states of consciousnessExchangeable terms include parts, dissociative parts, personality states, self-states, states, identities, selves, or ego states. Alters are present only in those with dissociative identity disorder or similar presentations of other specified dissociative disorder, where the parts of the personality are highly dissociated and isolated. No alter, including the host alter, is a complete personality, even though an alter might feel as if they are. <ref name=Howell2011/>{{Rp|55-67}}Alters are psychodynamically interacting parts, each with their own separate centers of subjectivity, identity, autonomy, and sense of personal history. <ref name=Howell2011/>{{Rp|55}}An individual with dissociative identity disorder may have few or many |alters, which include a variety of ages, cross gender, animal or objects, with coconsciousness (see coconsciousness) at varying degrees, and [[communication]] can be limited to one direction. (one way amnesia) <ref name=Dell2009/>{{Rp|301}}, (Howell, 2011) however at the far end of the spectrum are those who are said to be polyfragmentedPolyfragmented dissociative identity disorder. Most individuals with dissociative identity disorder have less than a dozen alters, however the far end of the spectrum is those individuals who are polyfragmented, having many alters which are subdivided into subsystems. <ref name=Howell2011/>{{Rp|57}} "In general, the complexity of dissociative symptoms appears to be consistent with the severity of early traumatization." <ref name=Chu2011/> In a polyfragmented system, the alters are broken into subsystems (see systems) as a method of self-preservation and organization of trauma memories. Polyfragmented dissociative identity disorder often develops in children who suffered very early (as an infant) and extreme abuse, either at home or from ritual abuse.<ref name=Miller2012/> and have many ANP and EP. (Howell, 2011, p. 57) [10] The complexity of dissociative symptoms appear to be consistent with the severity of early tramatization. (Chu, 2011)

    Notes

[11][12][13][14][15][9][16][1] [2] [17] [10][18]


Related project

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

References

  1. ^ Chu, James A. (2011). Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders. Hoboken, N.J.:John Wiley & Sons.ISBN 0470768746.
  2. ^ a b c Dell, P. (2009). Dissociation and the dissociative disorders : DSM-V and beyond. London:Routledge.ISBN 0415957850.
  3. ^ a b c d Howell, Elizabeth F. (2011). Understanding and Treating Dissociative Identity Disorder: A Relational Approach Volume 49 of Relational Perspectives Book Series. New York:Routledge/Taylor & Francis Group, 2011.ISBN 0415994977.
  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. ^ a b c Siegel, Daniel (2011). The Developing Mind 2nd edition. New York:Guilford.ISBN 1462503926, 9781462503926.
  6. ^ a b Putnam, Frank (1989). Diagnosis & Treatment of Multiple Personality Disorder,. The Guilford Press.ISBN 10: 0898621771.
  7. ^ a b Dorahy, Martub; van der Hart, Onno (2014). DSM-5’s PTSD with Dissociative Symptoms: Challenges and Future Directions, Journal of Trauma and Dissociation. 15, volume 1. (doi:10.1080/15299732.2014.908806)
  8. ^ Turkus, Joan. The Spectrum of Dissociative Disorders: An Overview of Diagnosis and Treatment. retrieved on 31 July 2014
  9. ^ a b Dell, P.F.. A new model of dissociative identity disorder. Psychiatric Clinic North America, volume 29, issue 1, page 1-26. (doi:10.1016/j.psc.2005.10.013)
  10. ^ a b c 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)
  11. ^ 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)
  12. ^ 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
  13. ^ 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)
  14. ^ Brand, B.; Richard J. Loewenstein, (2010). Dissociative disorders: An overview of assessment, phenomenology, and treatment. Psychiatric Times.
  15. ^ American Psychiatric Association, (1994). Diagnostic and statistical manual of mental disorders:DSM-IV. American Psychiatric Association.ISBN 0890420629.
  16. ^ Diagnostic and Statistical Manual of Mental Disorders-5.
  17. ^ 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)
  18. ^ Sar, Vedat. Epidemiology of Dissociative Disorders: An Overview. Epidemiology Research International, volume 2011, 1 January 2011, page 1–8. (doi:10.1155/2011/404538)