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Dissociative identity disorder: adaptive deception of self and others.

Dissociative identity disorder (multiple personality) is increasingly diagnosed, often follows childhood trauma, and is characterized by rigidification of phenomena that resemble hypnosis. To interpret dissociated aspects of selfhood as autonomous entities is a useful heuristic; but when taken too literally, it leads to three kinds of anomaly: (1) legal: dissociators remain culpable for misdeeds carried out beyond apparent awareness or control; (2) clinical: legitimization sometimes leads not to relief, but to escalating cycles of regressive dependency; and (3) scientific: the form of dissociated entities varies with how they are defined, in ways that are intrinsically motivated and clinically manipulable. These anomalies yield to an evolutionary perspective that views dissociative identity disorder as an evolved strategy of adaptive deception of self and others; e.g., a beaten subordinate avoids further retribution by "pleading illness." Such a deceit best avoids detection when fully experienced; through its intensity and persistence, it becomes real at a new level. One's basic competencies remain intact, however, and are the source of the anomalies described. They can be clinically accessed and empowered, providing the key to therapeutic change when dissociative processes are problematic. Overall, despite clear impairment in subjective awareness and volition, dissociative-disordered individuals are best held fully accountable for the consequences of their actions.

Awareness↗

Epidemiology of multiple personality disorder and dissociation.

A recent survey of a large sample of the general population in the city of Winnipeg, Manitoba, showed that multiple personality disorder related to childhood abuse affects about 1% of the adult population. About 10% of the adult population has had a DSM-III-R dissociative disorder of some kind. Pathologic dissociation appears to be a major form of emotional disturbance in North America, and it appears to be about as common as anxiety, mood, and substance abuse disorders. The dissociative disorders can no longer be considered rare.

Borderline Personality Disorder↗

Dissociative phenomenology of dissociative identity disorder.

The goal of this study was to investigate the dissociative phenomenology of dissociative identity disorder (DID). The Multidimensional Inventory of Dissociation (MID) was administered to 34 patients with DID, 23 patients with dissociative disorder not otherwise specified (DDNOS), 52 patients with mixed psychiatric disorders, and 58 normal individuals. DID patients obtained significantly higher scores than the other three groups on 27 dissociation-related variables. DDNOS patients had significantly higher scores than normals and mixed psychiatric patients on 17 and 15 dissociation-related variables, respectively. The findings of the present study are virtually identical to a large body of replicated findings about the dissociative phenomenology of DID. This broad range of dissociation-related phenomena, which routinely occurs in individuals with DID, is largely absent from the DSM-IV-TR account of DID. Factor analysis of the 11 dimensions of dissociation that are measured by the MID extracted only one factor that accounted for 85% of the variance. It was concluded that dissociation is a unifactorial taxon or natural type that has different aspects or epiphenomena (i.e., amnesia, depersonalization, voices, trance, etc.).

Adult↗

Trauma-related dissociative (conversion) disorders in children and adolescents--an overview of assessment tools and treatment principles.

A high proportion of patients in child and adolescent psychiatry with significant dissociative symptomatology after early childhood traumatization may go undiagnosed, be wrongly diagnosed and/or inappropriately treated. The diagnostics and treatment of dissociative disorders have been limited by lack of comprehensive, reliable and valid instruments and the ongoing polarization and fierce controversy regarding treatment. However, recent neurobiological findings of neurochemical, functional and structural cerebral consequences of early stressful childhood experiences point out a need for active, early and effective identification and treatment interventions. We present an update on assessment tools available in the Nordic countries, and an overview of different appropriate therapeutic intervention models for children and adolescents. A systematic overview of studies of dissociation in children and adolescent published over the last decade disclosed a total of 1019 references. The 465 papers describing aspects of assessment tools and/or treatment were studied in detail. Reliable and valid screening questionnaires and diagnostic interviews for children and adolescents now allow for effective early identification of dissociative disorders. A combination of individual psychotherapy, pharmacotherapy and family therapy are often required to handle dissociative disorders in children and adolescents. Cognitive-behavioural therapy, hypnotherapy, Eye-Movement Desensitization-Reprocessing (EMDR), psychodynamic therapy and an integrated approach are the main described psychotherapeutic approaches, but treatment of dissociation in children and adolescent does not require allegiance to any one particular treatment model. However, achievement of physical safety by providing a safe environment is a primary goal that supersedes any other therapeutic work. Assessments tools are now available, and appropriate therapeutic intervention models may hopefully contribute to reduce the risk of wrong diagnoses and inappropriate treatment of dissociative symptomatology in children and adolescents. However, controlled clinical trials of the various interventions and longitudinal outcome studies are needed.

Adolescent↗

Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder.

OBJECTIVE: The skepticism regarding the existence of dissociative identity disorder as well as the abuse that engenders it persists for lack of objective documentation. This is doubly so for the disorder in murderers because of issues of suspected malingering. This article presents objective verification of both dissociative symptoms and severe abuse during childhood in a series of adult murderers with dissociative identity disorder. METHOD: This study consisted of a review of the clinical records of 11 men and one woman with DSM-IV-defined dissociative identity disorder who had committed murder. Data were gathered from medical, psychiatric, social service, school, military, and prison records and from records of interviews with subjects' family members and others. Handwriting samples were also examined. Data were analyzed qualitatively. RESULTS: Signs and symptoms of dissociative identity disorder in childhood and adulthood were corroborated independently and from several sources in all 12 cases; objective evidence of severe abuse was obtained in 11 cases. The subjects had amnesia for most of the abuse and underreported it. Marked changes in writing style and/or signatures were documented in 10 cases. CONCLUSIONS: This study establishes, once and for all, the linkage between early severe abuse and dissociative identity disorder. Further, the data demonstrate that the disorder can be distinguished from malingering and from other disorders. The study shows that it is possible, with great effort, to obtain objective evidence of both the symptoms of dissociative identity disorder and the abuse that engenders it.

Adult↗

Comparison of dissociative identity disorder with other diagnostic groups using a structured interview in Turkey.

Twenty patients with dissociative identity disorder (DID), 20 with schizophrenic disorder, 20 with panic disorder, and 20 with complex partial epilepsy were evaluated with the Dissociative Disorders Interview Schedule (DDIS) and the Dissociative Experiences Scale (DES). Subjects with dissociative identity disorder were more frequently diagnosed as having somatization disorder, past or concurrent major depressive episode, borderline personality disorder, depersonalization disorder, and dissociative amnesia than other groups. They reported Schneiderian symptoms and extrasensory perceptions more frequently. In their anamnesis suicide attempts, trance states, sleepwalking, and childhood traumas were more frequent than those in comparison groups. The secondary features of dissociative identity disorder and the DES score differentiated these patients from comparison groups significantly. DID has a set of clinical features different from that of schizophrenic disorder, panic disorder and complex partial epilepsy. The differences are similar to those yielded previously in studies from North America.

Adult↗

Evidence for associations among somatoform dissociation, psychological dissociation and reported trauma in patients with chronic pelvic pain.

This study investigates somatoform as well as psychological dissociation, somatization and reported trauma among patients with chronic pelvic pain (CPP). Women with CPP (n = 52) who were newly referred to a gynecology department, or whose pain had resisted treatment, completed standardized self-report questionnaires and received a structured interview for DSM-IV dissociative disorders. The prevalence of dissociative disorders in the sample was very low. As hypothesized, self-reported somatoform dissociation was positively correlated with self-reported psychological dissociation and features of DSM-IV dissociative disorders; women who reported more serious psychic trauma, in particular sexual and physical abuse, experienced more somatoform and psychological dissociation than women reporting less trauma, or no trauma at all; and the association of somatoform dissociation and reported trauma was stronger than the association of psychological dissociation and trauma. Physical abuse/life threat posed by a person predicted somatoform dissociation best. The results are consistent with findings among psychiatric patients, and, therefore, strengthen the thesis that somatoform dissociation, (features of) dissociative disorder, and reported trauma are strongly intercorrelated phenomena.

Adult↗

Malingering dissociative identity disorder: objective and projective assessment.

Verification of dissociative identity disorder presents challenges given the complex nature of the illness. This study addressed the concern that this disorder can be successfully malingered on objective and projective psychological tests. 50 undergraduate women were assigned to a Malingering or a Control condition, then completed the Rorschach Inkblot Test and the Dissociative Experiences Scale II. The Malingering group were asked to simulate dissociative identity disorder; controls received instructions to answer all materials honestly. Analysis indicated that malingerers were significantly more likely to endorse dissociative experiences on the Dissociative Experiences Scale II in the range common to patients with diagnosed dissociative identity disorder. However, on the Rorschach there were no significant differences between the two groups. Results suggest that the assessment of dissociative identity disorder requires a multifaceted approach with both objective and projective assessment tools. Research is needed to assess these issues in clinical populations.

Adolescent↗

Structured interview data on 35 cases of dissociative identity disorder in Turkey.

OBJECTIVE: The aim of this study was to describe the clinical features of dissociative identity disorder in a group of Turkish patients as assessed with a structured interview. METHOD: Thirty-five consecutive patients at the dissociative disorders program of a university psychiatric clinic who met the DSM-IV criteria for dissociative identity disorder were included in this study. The subjects were assessed with the Turkish versions of the Dissociative Disorders Interview Schedule and the Dissociative Experiences Scale. A descriptive analysis of the clinical features was carried out. RESULTS: Most (88.6%) of the patients were women. The mean age of the group was 22.8 years. Childhood physical or sexual abuse was reported by 77.1% of the patients. The mean Dissociative Experiences Scale score was 49.1. The patients reported an average of 12.5 somatic symptoms, 6.2 Schneiderian symptoms, 10.0 secondary features of the disorder, 3.8 borderline personality disorder criteria, and 4.1 extrasensory experiences. CONCLUSIONS: Dissociative identity disorder has a stable, consistent set of features throughout North America, in the Netherlands, and in Turkey. Cross-cultural research using standardized assessment measures will be invaluable in further illumination of the validity of this widely neglected psychiatric category.

Borderline Personality Disorder↗

Pain-determined dissociation episodes.

OBJECTIVES: Dissociation disorders are a group of conditions characterized by a disruption of integrated function of consciousness, memory, or perception. The purpose of this report is to describe the impact of increased pain levels on the genesis of two types of dissociation disorders, dissociative fugue ( DF) and dissociative identity disorder ( DID), in patients with chronic pain ( PWCP). DESIGN/PATIENTS/INTERVENTIONS/OUTCOME MEASURES: From November 1992 to July 2000, 2 DID and 4 DF patients were identified from 2,544 consecutive PWCP evaluated and/or treated at the University of Miami Comprehensive Pain and Rehabilitation Center. The salient features of these six dissociation PWCP are presented. All four DF PWCP completed a dissociation experience scale first at the time of identification of the dissociation disorder (with chronic pain) and one alleging their experiences with dissociation predevelopment of chronic pain. RESULTS: Frequency percentage for dissociation for this population was 0.235%. For all four of the DF PWCP, dissociation episodes began after the onset of chronic pain. All six (100%) PWCP described or associated their episodes of dissociation to times when their pain would increase. Mean dissociation scale scores for the four DF PWCP were 1.4 +/- 1.11 pre-chronic pain and 20.53 +/- 16.82 at time of identification of the dissociative disorder (with chronic pain). CONCLUSIONS: The frequency percentage for dissociation within PWCP is small compared with psychiatric populations. There may be an etiological association between the development of dissociation episodes and the development of chronic pain and/or increases in chronic pain.

Journal Article↗

Hypnosis, childhood trauma, and dissociative identity disorder: toward an integrative theory.

It is contended that prevailing exogenous trauma theory provides in most cases neither a sufficient nor a necessary explanation for the current large number of diagnosed cases of dissociative identity disorder (multiple personality disorder) and related dissociative syndromes purported to have arisen as a response to severe early childhood physical and sexual abuse. Relevant aspects of instinctual drive theory, ego psychology, object relations theory, self psychology, social psychological theory, sociocultural influences, and experimental hypnosis findings are drawn on to demonstrate the importance of adopting a more integrative theoretical perspective in the diagnosis and treatment of severe dissociative syndromes. Further cooperative experimental and clinical research on the etiology, prevalence, and clinical manifestations of the group of dissociative disorders is strongly encouraged.

Adult↗

Psychosocial stressors that precipitate dissociative trance disorder in Singapore.

OBJECTIVE: To study the psychosocial stressors that precipitate dissociative trance disorder (DTD) and to identify predictors of DTD. METHOD: We conducted semistructured interviews in which detailed information was obtained for 58 cases diagnosed with DTD at a psychiatric hospital in Singapore. A comparison group of 58 patients who received treatment at the same hospital for major depression (MD) were also interviewed, using the same instrument. RESULTS: While 100% of the DTD group described at least one psychosocial stressor, only 80% of the MD group did so. Common stressors for the DTD group include problems with military life (38%), conflicts over religious and cultural issues (38%), and domestic disharmony and marital woes (24%). Conflicts over religious and cultural issues seemed to be important in the precipitation of DTD but not in the precipitation of MD (p < 0.001). Logistic regression reveals that the following are positive predictors for DTD: conflicts over religious and cultural issues; prior exposure to trance states; and being a spiritual healer or his/her assistant. CONCLUSIONS: An understanding of the precipitating psychosocial stressors that overwhelmed the patient's coping abilities would have implications for treatment and enable the clinician to devise strategies for intervention and prevention.

Adolescent↗

Perceptual and conceptual priming in patients with dissociative identity disorder.

The present study examined implicit memory transfer in patients with dissociative identity disorder (DID). To determine priming impairments in DID, we included both several perceptual priming tasks and a conceptual priming task using neutral material. We tested a large sample of DID patients (n = 31), in addition to 25 controls and 25 DID simulators, comparable on sex, age, and education. Controls replicated conceptual priming results of Vriezen, Moscovitch, and Bellos (1995) by showing that conceptual priming seems to require the formation of domain-specific semantic representations, denoting either sensory or functional object attributes. We extended a study performed by Schacter, Cooper, and Delaney (1990) by demonstrating priming for impossible object using the sensitive priming index of response times. The simulators in the study were not able to simulate interidentity amnesia on the implicit memory tasks employed. Partly in contrast to participants in previous studies, DID patients showed evidence of perceptual priming as well as conceptual priming comparable to that of controls. DID patients thus displayed normal implicit memory performance.

Adult↗

The sociocognitive model of dissociative identity disorder: a reexamination of the evidence.

According to the sociocognitive model of dissociative identity disorder (DID; formerly, multiple personality disorder), DID is not a valid psychiatric disorder of posttraumatic origin; rather, it is a creation of psychotherapy and the media. Support for the model was recently presented by N.P. Spanos (1994). In this article, the author reexamines the evidence for the model and concludes that it is based on numerous false assumptions about the psychopathology, assessment, and treatment of DID. Most recent research on the dissociative disorders does not support (and in fact disconfirms) the sociocognitive model, and many inferences drawn from previous research appear unwarranted. No reason exists to doubt the connection between DID and childhood trauma. Treatment recommendations that follow from the sociocognitive model may be harmful because they involve ignoring the posttraumatic symptomatology of persons with DID.

Adult↗

Rorschach indicators of dissociative identity disorders: clinical utility and theoretical implications.

The purpose of the present study was to replicate Rorschach signs of Multiple Personality Disorder (MPD) using DSM-IV criteria of Dissociative Identity Disorder (DID). Women admitted to either an inpatient dissociative disorder's unit (n = 27) or a general psychiatric unit (n = 72) were given the Rorschach, which was scored for the Labott, Barach, and Wagner Rorschach markers of MPD. Results indicated that Rorschach signs of the three different systems were significantly better than chance at classifying patients as DID or as non-DID. The Labott system, which performed the best, was able to accurately classify 92% of the sample. These results argue for the validity of the DID diagnosis. The Rorschach signs operate independent of external bias, yet correspond to the diagnoses obtained through psychiatric evaluation in an inpatient setting. The fact that two relatively rare sets of signs (DID and Rorschach) converge in the same small sector of the psychiatric population represents evidence of linkage that is clinically meaningful and not explainable on the basis of artificial creation.

Adolescent↗

Dissociative trance disorder: clinical and Rorschach findings in ten persons reporting demon possession and treated by exorcism.

Although dissociative trance disorders, especially possession disorder, are probably more common than is usually though, precise clinical data are lacking. Ten persons undergoing exorcisms for devil trance possession state were studied with the Dissociative Disorders Diagnostic Schedule and the Rorschach test. These persons had many traits in common with dissociative identity disorder patients. They were overwhelmed by paranormal experiences. Despite claiming possession by a demon, most of them managed to maintain normal social functioning. Rorschach findings showed that these persons had a complex personality organization: Some of them displayed a tendency to oversimplify stimulus perception whereas others seemed more committed to psychological complexity. Most had severe impairment of reality testing, and 6 of the participants had an extratensive coping stile. In this group of persons reporting demon possession, dissociative trance disorder seems to be a distinct clinical manifestation of a dissociative continuum, sharing some features with dissociative identity disorder.

Adult↗

Dissociative identity disorder and pseudo-hysteria.

The diagnostic validity of dissociative identity disorder (DID) continues to inspire controversy, with some commentators claiming that DID is a modern variant of "hysteria"; that is, attention-seeking behavior. The author asserts that DID is indeed a valid psychiatric disorder, and believes that this skeptical reaction can largely be attributed to a specific set of transference/countertransference interactions that these patients tend to inspire. The paper delineates several clinical features of DID that can easily be mistaken for hysterical phenomena, and attempts to find the roots of this confusion in the DID patients' experience of interpersonal powerlessness, which leads them to present their symptoms in an unconvincing, "hysterical" manner. Confusion between the vertical split seen in the dissociative disorders and the horizontal split characteristic of the classic hysterical personality is discussed, as is the powerful effect of observer bias in creating hysterical-appearing phenomena. The term "pseudo-hysteria" is used to denote a situation in which a genuine psychiatric disorder, DID, is perceived as an hysterical production.

Diagnosis, Differential↗

Psychobiological characteristics of dissociative identity disorder: a symptom provocation study.

BACKGROUND: Dissociative identity disorder (DID) patients function as two or more identities or dissociative identity states (DIS), categorized as 'neutral identity states' (NIS) and 'traumatic identity states' (TIS). NIS inhibit access to traumatic memories thereby enabling daily life functioning. TIS have access and responses to these memories. We tested whether these DIS show different psychobiological reactions to trauma-related memory. METHODS: A symptom provocation paradigm with 11 DID patients was used in a two-by-two factorial design setting. Both NIS and TIS were exposed to a neutral and a trauma-related memory script. Three psychobiological parameters were tested: subjective ratings (emotional and sensori-motor), cardiovascular responses (heart rate, blood pressure, heart rate variability) and regional cerebral blood flow as determined with H(2)(15)O positron emission tomography. RESULTS: Psychobiological differences were found for the different DIS. Subjective and cardiovascular reactions revealed significant main and interactions effects. Regional cerebral blood flow data revealed different neural networks to be associated with different processing of the neutral and trauma-related memory script by NIS and TIS. CONCLUSIONS: Patients with DID encompass at least two different DIS. These identities involve different subjective reactions, cardiovascular responses and cerebral activation patterns to a trauma-related memory script.

Adult↗