Dissociative Identity Disorder

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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, 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}} (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}}) is determined when an individual shows they posses multiple parts of their personality with distinct dissociative boundaries between two or more of those parts. A distinct part is not one that holds trauma memories, but are the parts that attend to daily life. In the theory of structural dissociation of the personality this part is called an apparently normal part (ANPA distinct state who performs the job of daily activities and does not hold trauma memories. Dissociative identity disorder is the only mental disorder where an individual can have two or more ANP. <ref name=HauntedSelf/> {{See also| structural dissociation}}), so it is said that when two ANP switch the disorder is dissociative identity disorder.(Dalenberg, 2012) The DSM-5 lists four criteria that must be met for a diagnosis, and anyone with training in the diagnosis of complex dissociative disorders understands this. (Nijenhuis et al., 2011) It's unlikely that the layman understands the DSM-5 criteria well enough to diagnose the complex dissociative disorders, and the same is true for mental health professionals who have not been trained in the necessary intricacies of the two disorders.(Dell, 2009, p. 383-402)(Obsuth et al., 2014)(Solomon et al., 2010)(Steele et al., 2001)(Spiegel, 2014)

Paul F. Dell led a drive to separate the complex dissociative disorders from other disorders. His multi-authored, 864 page book titled: Dissociation 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.(Kluemper et al., 2014)(Siegel, 2010) There was little agreement at that time and the massive text book strongly reflects this. 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.(Chu, 2011)(Whitfield, 1995)

Pierre Marie Félix Janet, amid an onslaught of naysayers determined that the minds ability to dissociate, a term he coined, was influenced by what he called "dissociative determinations," which today we refer to as subjective traumas.(Whitfield, 1995)Janet insisted that the mind is made up of a network of neurons that, when healthy, work together in harmony, but when "infected" by a trauma memory are the mind has no choice but to react to and interact with stimulus.(Loewenstein et al., 2014)(Whitfield, 1995) While the process has its purpose, for the most part it is counter productive. (Siegel, 2012)(Steele et al., 2001)
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Janet observed an individuals reaction to trauma and understood it, but this important knowledge was stifled by Dr. Cornelia Wilbur, who was responsible for the story of "Sybil."(Whitfield, 1995) Prior to the media circus brought forth by "SybilSybil is a biography describing the life of a woman with suppose dissociative identity disorder, (which was thought to actually be otherwise specified dissociative disorder) published as a book in 1973 and released as a TV movie in 1976.The diagnosis of dissociative identity disorder began 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/>{{See also| History of DID}}" was "Three Faces of Eve," then Billy Milligan's story. The symptoms and presentation were mixed portrayals of dissociative identity disorder, and other specified dissociative disorder. All this confusions created a Frankenstein effect that was more fantasy than reality.(Chu, 2011)Janet's work became lost in the popular media flap and there it stayed for the most part, until Ellert R. S. Nijenhuis dug into the original writings of Janet and brought them to light.(Obsuth et al., 2014) Nijenhuis, a brilliant 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 psychotherapistPyschotherapists 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. himself, was able to make sense of what he found.(Obsuth et al., 2014) In fact, he did more than that. He demanded that Janet's work be heard and understood. Onno van der Hart, another brilliant psychotraumatomologist and mentor to Nijenhuis, aided in the work and together they processed the important historic information.(Lanius et al., 2010) Later, Kathy Steele joined the two men 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 Dissociation and the Treatment of Chronic Traumatization. (Vanderhart et al., 2006). There were earlier journal articles by the three authors, but it was the book that fully introduced the concept of what today is called structural dissociation of the personality.(Vanderhart et al., 2006)(Dell et al., 2009, p. 3-26)

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 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 reference lists the criteria for dissociative identity disorder. The two main criteria are as follows.

• Disruption of identity characterized by two or more distinct personality states.(DSM5, 2013)

The above criteria in the DSM-5leaves many people confused about what states need to be identified.(Dell et al., 2009, p. 383-402)(Vanderhart et al., 2006)(Frewen et al., 2014) To be clear, the part of the personality that holds 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}} (often referred to as an EPAn state that holds trauma memory. A term used in structural dissociation. <ref name=HauntedSelf/>{{Rp|38-39}}) is not defined as a "distinct 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}}." The understanding of this reduces the confusion surrounding dissociative identity disorder and otherwise specified dissociative disorder to a small roar.

Amnesia between distinct parts 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}}, not between states that hold trauma memory.(Nijenhuis, 2011b)

The DSM-5 does not define the type of amnesiaMemory loss. {{See also| amnesia}} they refer to, but it's clear that only in dissociative identity disorder is there 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}} between two distinct parts (parts that attend to daily life that are often referred to as ANP). There are five known types of amnesia: generalized, systematized, localized, continuous, selective.(Siegel, 2012)(Siegel, 2010)

See the paragraph below to understand the meaning of an EP and ANP.

See also DSM.

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Introduction to structural dissociationStructural dissociation (SD) is one of the three accepted etiological ideas for the etiology of dissociative identity disorder. <ref name=HauntedSelf/> <ref name=Dell2009/>{{Rp|158-165}} It also explains other specified dissociative disorder, dissociative forms of borderline personality disorder, and dissociative posttraumatic stress disorder {{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. of the personality

Structural dissociation of the personality and its understanding makes the process of identifying and understanding dissociative identity disorder easier.(Kluemper et al., 2014) Someone with dissociative identity disorder has two or more apparently normal parts (ANP) and two or more emotional parts (EP), while the other complex dissociative disorder known as otherwise specified dissociative disorder has only one ANP, but also two more more EP.(Vanderhart et al., 2006) If a diagnosis is narrowed down to one of the two complex dissociative disorders and if an ANP only switches from ANP to EP or EP to ANP 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.(Vanderhart et al., 2006)(Steele et al., 2001)

The ANP attend to daily life, as opposed to EP, which are the parts stuck with trauma memory. To diagnose dissociative identity disorder, according to the DSM-5, there needs to be a distinct and disturbing loss of memory between two distinct states. Although the DSM does not spell it out as plainly, a switch from one ANP to another ANP is what is observed when a diagnosis of dissociative identity disorder is given. Now with this brief tutorial under your belt, let's take a look at an example.(Schlumpf et al., 2014)(Dorahy et al., 2014)(Steele et al., 2001)

Understanding dissociative identity disorder through structural dissociation

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Let's use an example to explain how all this works. Our vignette will be of a woman named Annabelle who 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. is Dr. Getsitright. Annabelle presents to him on her first visit with obvious amnesia and distinct parts of her personality.

Annabelle knocks on Dr. Getsitright's door, a mental health professional whom she has never met before, but who she does have an appointment with. She has come to him because she has had an eating disorder for years and is at her wits end about it. The doctor answers the door and invites her to have a seat in his small office. She looks confused for a moment, but comes inside the room anyway. 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. First she picks up a toy truck and a big grin comes to her face. Dr. Getsitright asks if she would like to play with it. Startled she puts the truck back on the shelf, seemingly ignoring what the Doctor said. Then her attention goes to the children's books. Dr. Getsitright has a magnificent display of them. There are also psychology books, scientific journals, books on knitting, crafts, cooking, home projects and art books. Dr. Getsitright notices Annabelle's interest the children's books on sculpting play dough and he asks if she would like to borrow one. She dismisses his question and abruptly 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 notices a shift in her presence, voice and tone now for the third time during their short visit. Now she now appears to be disturbed by the doctor's waste of her time. She says, in a distinctly different tone than before, 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 again shifts her posture, this time to a familiar one, and she answers, why of course I am. You and I already introduced ourselves. Why ever would you ask such a foolish question?(Schlumpf et al., 2014)(Nijenhuis et al., 2011b)(Steele et al., 2001)

The first ANP that came into the office was unsure where she was at. That ANP switches to is another ANP, so let's call them ANP 1 and ANP 2 so we can distinguish them. ANP 2 greets the doctor and accepts she is there for therapy. We have now seen an ANP switch from one ANP to another, but that was so quick the doctor needs more information. The next switch is to an EP. How do we know that? The trained therapist can usually tell when a childlike part comes out. The EP is the part that picked up the toy truck. Then the doctor's voice startled the EP, the she put the truck down, as a new ANP took her place. We will call this one ANP 3. A switch from an ANP to an EP is not what we are looking for since other disorders switch from an ANP to an EP to an ANP. The next switch is to another EP, which is the one interested in a book on play dough. That could mean a number of different disorders. We are looking for a switch from an ANP to another ANP. The second EP is replaced by an ANP that wants to get to get to work and chastises the doctor for wasting her time. That's when he asks her name and as a result there is a switch from an ANP to another ANP, and in fact to the familiar one that first walked through the door. Now the doctor has a very good idea what to test Annabelle for. He is quite confident he has now seen her switch from an ANP to another ANP.(Schlumpf et al., 2014)(Nijenhuis et al., 2011b)(Steele et al., 2001)

The first point of this vignette was to show that amnesia can be observed between distinct parts of the personality. Annabelle, in her short time in Dr. Getsitright's office has displayed amnesia in all five ways possible. The five types of amnesia include the following: amnesia between the ANP, which is seen when Annabelle does not remember the time between her introduction to Dr. Getsitright. The next form of amnesia presented 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 a book from the shelf. 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 in this example, but when Annabelle walked into the office an astute observer would have been able to tell that she did not remember knocking on the door. In addition, an ANP will usually 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 and amnesia between two ANP.(Obsuth et al., 2014)(Vanderhart et al., 2006)(Nijenhuis et al., 2011b)(Schlumpf et al., 2014)(Steele et al., 2001)

Symptoms

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The 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, but keep in mind that just because someone does not realize there is something very wrong with them does not make them mentally healthy. The main symptom of dissociative identity disorder, dissociation, reduces distress and acts as a coping mechanism, but at the same time causes its own mental and physical impairments.(Dell et al., 2009, p. 447-469)

Etiology

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 thought to occur when a child is unable to develop a unified sense of self.(ISSTD, 2011, p. 133)(Dell et al., 2009, p. 571-584) There are three etiological models accepted by the International Society for the Study of Trauma and Dissociation (ISSTD), an international organization which defines the top experts in the field of trauma and 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}}, and all three ideas 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 et al., 2009, p. 585-598)Psychological trauma and dissociation are entwined closely.(Siegel, 2010) When early trauma is chronic and severe, it can result in dissociation and 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.(Siegel, 2012) In addition, a combination of trauma and chronic emotional neglect in early childhood leads to attachment abnormalities, which are prevalent among those with dissociative identity disorder.(Ross et al., 2011) Age is also a critical factor in the development of dissociative identity disorder.(Schlumpf et al., 2014)(Siegel, 2012)(Chu, 2011) In fact, Onno van der Hart and Ellert Nijenhuis have shown evidence that for someone to have dissociative identity disorder an infant must have been infected with the strata that lays the groundwork for the disorder, which is either purposeful or unintentional neglect, and lack of 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}}.(Vanderhart et al., 2006) In that same vein, age is an important influence on the mind resulting in trauma.(Loewenstein et al., 2014)

"The age of the individual at the time of early and chronic trauma is a critical component due to the developmental processes that, under other circumstances, would normally occur at that time. (NICE, 2005) In addition, the age at the beginning and the ending of the trauma is significant as it encompasses the sequence of developmental stages and should influence which developmental tasks are most disrupted.(Chu, 2011) It appears as if vulnerability to dissociation increases if the trauma occurs at earlier developmental stages." (Gentile et al., 2013)(Dell et al., 2009, p. 39-146)Etiology is best understood through the understanding of structural dissociation of the personalty.(Loewenstein et al., 2014) Let's look at an example of etiology using the concept of structural dissociation of the personality.

Anabelle was born a few days ago and she has already been suffocated, starved and has not felt the love and comfort of any caretaker. She is vulnerable to all sorts of mental disorders because of this neglect.(Siegel, 2012)(Chu, 2011) Let me make clear that when neglect is mentioned, it means all neglect and that includes the neglect of a caretaker to keep the child from harm.(Siegel, 2012) What direction 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/> and/or neglect take in 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 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}}, if any, a child will get.(Siegel, 2012)(Vanderhart et al., 2006) Any human who has been neglected or abused in early infancy has the potential to have dissociative identity disorder. It's not genetic. This is an environmental disorder.(Siegel, 2012)(Vanderhart et al., 2006)

Let's take a look at Annabelle and see how the stratum for dissociative identity disorder was put in motion in the first weeks of her life. Annabelle is less than six-weeks old and she lies in her crib and is alone with her thoughts. She is rarely to never comforted, held, or played with. She is hungry, her diaper is never changed, and she is in pain. There is no one to respond to her basic needs, so what does that do to her mind? According to most experts, it causes what is known as disorganized attachment.(Siegel, 2012)(Chu, 2011) That's the first criteria met. In addition, she is not forming an attachment to a caregiver and her cries are met with anger and she learns not to respond to the pain of hunger, or any of her other basic needs.(Siegel, 2012) She is learning a basic animal response.(Siegel, 2012)(Chu, 2011)(Dell et al., 2009, p. 93-106) The infant in this situation becomes lethargic and fails to thrive and dies, or learns to ignore the pain by learning to dissociate.(Loewenstein et al., 2014)(Dell et al., 2009, p. 185-196) There is more going on in this infants head than her new learned ability to dissociate away pain. She is also learning to comfort and sooth herself.(Dell et al., 2009, p. 495-510) She only has herself, so that's where she turns.(Dell et al., 2009, p. 93-106) She listens inside for anything - anything at all. What she finds is subjective, but it also follows strict patterns developed through time as humans have evolved.(Dell et al., 2009, p. 329-372)

Etiology assuming the first six weeks of life resulted in lack of attachment

Annabelle is now one year old and she never cries. She displays the behavior observed in a child with disorganized attachment. She is confused. She needs a caregiver, but her's, in her experience, is not safe. This is evident in her behavior when she interacts with one.(Siegel, 2012) The brain needs nourishment and stimulation and she has not got enough of either in her life so far.(Siegel, 2012) The mind is different as it can create it's own stimuli, which it does in Annabelle's case. Her mind is actively stimulating her brain, and in fact it's doing it in excess to make up for the lack of external stimulation.(Dorahy et al., 2014)(Dell et al., 2009, p. 93-106) She is creating the base that is needed for her to have a complex dissociative disorder.(Schlumpf et al., 2014)(Siegel, 2012)(Chu, 2011)(Dell et al., 2009, p. 93-106) There are only two complex dissociative disorders and just one requires that Annabelle's first year of life involved unprocessed trauma.(Nijenhuis et al., 2014)

DSM-5 criteria defines the differences between DID and OSDD and other disorders

In this way, the DSM-5 misleads us, but at the same time the criteria are well written. We looked at them at the top of the page, but with more understanding now, let's look again. "Disruption of identity characterized by two or more distinct personality states," says it all. (Dell et al., 2009, p. 571 - 584) This simple statement eliminates all other disorders from consideration and here is how.

  • Schizophrenia has been confused with both other specified dissociative disorder and dissociative identity disorder, but the DSM-5 criteria have carefully been written to discourage this. For example, the criteria state that for an individual to have dissociative identity disorder there must be distinct states with their own way of being. In Schizophrenia there are no states. This is not a disorder that fits within structural dissociation. What is seen in Schizophrenia is a delusionalA delusion is a "false belief, based on incorrect inference about external reality, that is firmly held despite objective and obvious contradictory proof or evidence and despite the fact that other members of the culture do not share the belief." <ref name=Sadock2008/>{{Rp|24}}Delusional perception is a "perception that has a unique and idiosyncratic meaning for a person, which leads to an immediate delusional interpretation". A Schniederian first-rank symptom often associated with schizophrenia <ref name=Sadock2009/>{{Rp|1434}} but not associated with dissociative identity disorder. <ref name=Dell2009/>{{Rp|391}} pattern of one "state shifting".(Dell et al., 2009, p. 557-570)

    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}}

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Therapy is the primary treatment method and there are no medications to cure or manage dissociative identity disorder; 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.(Dell et al., 2009, p. 599-652)(Vermetten et al., 2014) Without the ability and education needed for astute observation the clinician can arrive at an incorrect diagnosis.(Dell et al., 2009, p. 637-652) Therefore only those trained to diagnosis complex dissociative disorders should do so.(Brand et al., 2014)

Prognosis

When untreated, there is chronic and recurrent symptoms varying over time including long-lasting effects such as suicidal tendencies, anxiety, and dissociative symptoms.(Brand et al., 2014)(Dell et al., 2009, p. 637-652) Some individuals feel that they function well at different times in their life but they are actually in a stage of denialPsychology - Defense mechanism in which the existence of unpleasant realities is disavowed; refers to keeping out of conscious awareness any aspects of external reality that, if acknowledged, would produce anxiety <ref name=Sadock2008/>{{Rp|24}}Crime - "various processes by which individual actors, social groups or states either 'block, shut out, repress or cover up certain forms of disturbing information [about wrong doing] or else evade, avoid or neutralize' its consequences. (Cohen (1995){{Rp|19}}) Refers to the denial of a perpetrator of a crime, for example denying the crime or the impact of the crime, denying the victim, counter-attacks and appealing to "higher loyalties".<ref name=CrimeDict/>{{Rp|125}} due to ANP phobiaPhobia of dissociated states is evident in all dissociative disorders, but in dissociative identity disorder it is highly evident..(Dorahy et al., 2014)(Brand, 2010)(Steele et al., 2001) At least four-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.(Brand, 2012)(Dell et al., 2009, p. 637-652) Estimates of patients that do obtain full integration range from 16.7% to 33%.(Loewenstein et al., 2014b)(Brand et al., 2009)

Epidemiology

Tools designed to assess dissociative disorders, yield lifetime prevalence rates around 10% in the clinical population.(Sar, 2011) 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. (ISSTD, 2011)

History

Multiple personality 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, 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}}, which of course is not a personality disorder, but was listed as a dissociative disorder. Today it's still well known and accepted that dissociative identity disorder is not a personality disorder. The label was pushed by Dr. Cornelia Wilbur in the early 1960's at a time when otherwise specified dissociative disorder, dissociative identity disorder, schizophrenia and even borderline personality disorder were all confused with one another.(Whitfield, 1995)(Vermetten et al., 2014) Those days are long past, and today's researchers and clinicians have little trouble telling these disorders apart or in knowing which individuals suffer from a dissociative disorder and which have a personality disorder.(Whitfield, 1995)

Related project

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

References

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