Dissociative Identity Disorder (DID) and Dissociative Phenomena

  • Dissociative Identity Disorder (DID) Overview

    • Abuse can lead to compartmentalization in children, often resulting in them internalizing blame ("you're the reason"). Predators may use rationalization for their actions.
    • Adults may also excuse their behavior, stating, "If you hadn't done this, then I wouldn't have gotten angry."
    • In DID, different personalities (alters) can be amnestic (unaware) of the actions of other personalities.
    • Individuals may infer another personality has been present by observing evidence, such as a neat or destructive environment.
    • Sometimes, an alter may inflict pain (e.g., cutting) on the body, with the core personality having no conscious awareness of the act, only the injury. Individuals may attribute this to a self-loathing or self-destructive alter.

  • Number of Personalities in DID

    • Popular literature often sensationalizes the number of personalities (7, 11, 23, 87).
    • Clinically, people with DID are generally thought to have about 5 to 10 distinct personality states.
    • When individuals report a much larger number, these are often considered "ego states" (fractions of a personality) rather than fully distinct personalities.
    • Fragment personalities can become more numerous during therapeutic interviews, as the querying process may inadvertently break down the cohesiveness of existing personalities.

  • Diagnosis and Prevalence

    • DID is a relatively rare disorder, meaning clinicians are less likely to initially consider it as a diagnosis.
    • It is frequently misdiagnosed as more common conditions such as depression, anxiety, or substance use problems.
    • Clinicians must be careful not to over-identify DID, especially if working in a population where its base rate is higher than general.
    • Case Study: The Three Faces of Eve
      • This famous case involved Eve (the central personality), Eve White (a demure, docile, submissive personality), and Eve Black (a seductive, adventurous, and reckless personality).
      • Years after the original psychiatrist passed away, leading questions in his interview tapes were discovered, suggesting he may have unconsciously encouraged the development or manifestation of these distinct personalities. This highlights the potential for iatrogenic (treatment-caused) influence.

  • Therapeutic Goals and Characteristics of Alters

    • The ultimate goal of therapy for DID is to fuse the personalities into a single, unified, central personality that can "steer the boat."
    • Alters can have vastly different identifying features and abilities (e.g., some wear glasses, some have higher pain tolerance, some have acute senses).
    • Example: One personality might have a constricted affect and high pain tolerance, developed to cope with childhood abuse. Another might have acute vision and steadiness, making them good at driving and marksmanship.

  • Theories on the Origin of DID

    • 1^{st} Theory: Extreme Stress/Childhood Trauma (Most Common)
      • Children possess greater neuroplasticity, allowing them to develop distinct brain circuitry more easily.
      • This enables them to develop personalities as a way to compartmentalize traumatic experiences.
      • The downsides include instability: problems can generalize, leading to more frequent switching, and alters can spend extended periods in control.
    • 2^{nd} Theory: Self-Hypnosis
      • Hypnosis alters consciousness and increases suggestibility.
      • Personal experience from research: being hyper-aware and focused on the hypnotist, eager to please.
      • Ernest Hilgaard at Stanford developed a standardized scale for suggestibility after over 30 years of research.
      • High suggestibility can lead to post-hypnotic suggestions (acting on a trigger without conscious memory) and the ability to experience positive (perceiving non-existent stimuli) or negative (not perceiving existing stimuli) hallucinations.
      • Stage hypnotists identify highly suggestible individuals through subtle cues (e.g., how readily they respond to commands like resisting arm lifts).
      • Most people are moderately suggestible. The lecturer is medium suggestible, unable to experience positive hallucinations, post-hypnotic suggestions, or altered pain thresholds.
      • The theory posits that individuals with DID essentially self-hypnotize and slip into dissociative states.
      • Many people experience dissociation (e.g., when tired, children immersed in play). Developing a sense of "self" is a developmental milestone, and children often struggle to differentiate fantasy from reality.
    • 3^{rd} Theory: Iatrogenic Factor (Treatment-Caused)
      • The increase in DID diagnoses in the US during the latter half of the 20^{th} century and subsequent decline in the 21^{st} century suggests that diagnostic trends might be influenced by external factors.
      • This theory proposes that DID or its presentation can be inadvertently created or encouraged by leading questions from interviewers.
      • Example: Child Witnesses
        • Children are highly suggestible; their testimonies can be easily altered by leading questions, especially if interviewed by multiple people.
        • A case involving a childcare center accused of satanic cult activities illustrates this, where therapists' improperly trained and leading interview techniques implanted false memories in children.
        • To avoid this, interviewers should: 1) exthyphen Limit the number of interviewers to ext{1} or ext{2}. ext{2} exthyphen Ask open-ended questions and avoid suggesting specific details.
      • Confirmation Bias: Once a hypothesis is formed (e.g., a specific diagnosis), there's a tendency to seek data that fits it, ignoring contradictory evidence.
        • This applies to law enforcement (leading to false confessions, as 12 ext{%} of people will confess to uncommitted crimes under stress to end an interview), medicine, and psychotherapy.
        • Professionals need to remain flexible, question their hypotheses, gather more data, and adjust their conclusions if evidence doesn't fit.
      • The Repressed Memory Movement:
        • In the past, some therapists encouraged clients to "recover" repressed memories, particularly of childhood abuse, and confront alleged perpetrators.
        • This led to significant problems: clients often developed false memories, confidentiality was breached, and professionals faced defamation lawsuits from accused individuals and malpractice suits from clients.
        • As a result, insurance companies stopped covering legal defense for such cases, leading to a decline in this practice.
        • Today, working with recovered memories requires specialized training, research, and rigorous protocols (e.g., videotaping sessions to ensure non-leading questioning).
      • Iatrogenic Definition: ext{Treatment-caused}. A physician-prescribed medicine causing illness, or a psychotherapist's incorrect diagnosis/suggestion that worsens a client's condition, are examples of iatrogenic effects.

  • Freudian Psychodynamic Perspectives

    • Repression: A key defense mechanism where traumatic or anxiety-provoking thoughts are unconsciously pushed into the unconscious mind.
    • Repression is the first defense mechanism children use and, like most defenses, is incomplete and tends to break down over time.
    • Its goal is to wall off anxiety-provoking memories to prevent them from affecting other areas of life.
    • However, unconscious material tends to resurface through dreams, Freudian slips (parapraxes), or impulses/wishes/fantasies, revealing underlying anxieties.
    • Dissociation is another defense mechanism used to distance oneself from painful memories.

  • Types of Dissociative Disorders (Beyond DID)

    • Dissociative Amnesia: Inability to recall personal information, usually of a traumatic or stressful nature. It often involves specific periods and tends to be temporary.
    • Dissociative Fugue: A more severe form of dissociative amnesia involving sudden, unexpected travel away from home or work, accompanied by amnesia for one's identity or other important autobiographical information. The individual may assume a new identity. Fugue literally means ext{"to flee."}
      • Individuals in a fugue state might create an entirely new life.
      • Recovery typically occurs within days to months, though sometimes years. Individuals often return to their previous life with amnesia for the fugue period.
      • Fugue episodes are often preceded by periods of depression, indicating that prior coping mechanisms have failed, leading to a "massive avoidance" as a psychological "release valve" from overwhelming stress (e.g., financial hardship, marital problems).
    • DID is a more complex form where the person shifts into different personality patterns that serve the purpose of managing anxiety.
    • Depersonalization/Derealization Disorder: These are less common than DID and involve experiences of feeling detached from one's body/mental processes (depersonalization) or from one's surroundings (derealization). Most people experience some mild episodes of these, but it becomes a disorder when these experiences become persistent or recurrent and cause significant distress or impairment.

  • Support for Psychodynamic Perspectives and Resilience

    • Over 70 ext{%} of DID cases in case studies report a history of child abuse, supporting the trauma theory.
    • A challenge is that some individuals with DID do not report trauma (which might be repressed).
    • It is crucial to study resilience – understanding why some individuals exposed to similar traumatic backgrounds do not develop dissociative disorders.
    • Protective factors that foster resilience include: security, sanctuary, supportive relationships (teachers, relatives, friends), engagement in groups or hobbies (sports, music) that meet needs in a safe way.
    • These connections can significantly reduce the likelihood of developing such disorders or improve coping, reducing reliance on maladaptive strategies like substance abuse.

  • Marijuana as a Dissociative Drug

    • Marijuana is considered a dissociative drug and carries risk factors for individuals prone to dissociative phenomena, depression, or schizophrenia.
    • It is neither harmless nor entirely harmful but has "predations" (risks).
    • Many people use marijuana, alcohol, or central nervous system depressants as a way to self-medicate anxiety through dissociation (e.g., "If I dissociate under a drug, I don't care.").

  • Hypnosis, Memory, and Legal Implications

    • Similarities exist between dissociative amnesia and hypnotic amnesia.
    • Hypnosis can be used to enhance memory, but extreme caution is needed to avoid suggestion.
    • Hypnotically enhanced or induced memories are inadmissible in court because, while witnesses often speak with great conviction and appear credible (due to non-verbal cues), the actual accuracy of such memories is low.
    • Eyewitness testimony is only accurate about 60 ext{%} of the time.
    • Polygraphs are between 25 ext{%} and 75 ext{%} accurate, depending on administration, and are also inadmissible in court due to unreliability.

  • DID and Related Disorders

    • In DID, alters can adopt characteristics that enhance survival, such as pain numbness or seductiveness, leveraging neuroplasticity under extreme motivational states.
    • PTSD and acute stress disorder are considered related to dissociative disorders because they involve similar dissociative defense mechanisms.
    • Defense mechanisms operate largely automatically, like the autonomic nervous system, with both top-down and bottom-up influences.
    • Dissociative amnesia and fugue episodes are generally time-limited, with most individuals recovering and returning to their lives.

  • Therapeutic Process for DID

    • Initial screening for common comorbidities (anxiety, depression, substance use, interpersonal difficulties) is often done by general clinicians, leading to specialists receiving cases more likely to be DID.
    • A specialist's risk is over-identifying DID due to their focus.
    • Therapy helps clients understand the nature of DID, including mood instability and relationship difficulties caused by unconscious switching.
    • Efforts include recovering amnestic gaps.
    • Alters can have varying levels of awareness: some know others, some are unaware, some know all, or some deduce other presences from behavioral traces (e.g., changed environment, unknown journal entries).
    • The goal is fusion, a process where sub-personalities are gradually integrated into one cohesive, core personality. This doesn't mean other aspects disappear entirely, but the core personality gains central control (as seen in the eventual "fusion" of Eve White and Eve Black into a unified Eve).