Chapter 8

Dissociative identity disorder or DID was previously known as multiple personality disorder. In order to qualify for the disorder, there must be at least two distinct and separate personalities or alters within the same person with only one personality in control at any given period of time. The different personalities affect the individual’s behavior and conduct when they are “present.” The disorder cannot be from a drug or alcohol addiction and cannot be due to a medical/neurological disorder (such as epilepsy). This has been a controversial diagnosis that has been attributed to misdiagnosis, hysteria, or hypnotic suggestion. This means that only a small number of psychiatrists are well-trained to make the diagnosis or treat people who have DID. The symptoms are sometimes difficult to differentiate from other types of disorders—both mental and physical. It can be similar to seizure disorders, PTSD, and substance use disorders, which must be ruled out as possible causes. Typical symptoms include an inability to recall significant memories of childhood, lack of awareness or inability to explain certain activities, unexplained sleep disorders, eating and food issues, anxiety or panic attacks, mood swings, 126 changes in handwriting, self-harm or suicidal ideation, out of body experiences, hearing voices or having out of body experiences, detachment or disconnection from body or thoughts, lost time (one of the major features), and flashbacks or sudden return of memories. Less commonly seen in DID are mood swings, depression, anxiety symptoms, eating issues, sleep problems, headaches or body pain, and sexual issues like sex addiction or sexual avoidance. The general prevalence of DID is about 0.4-3 percent, which is a wide variation but speaks to the fact that it is difficult to diagnose and the fact that there are a number of undiagnosed individuals with the disorder. The onset of dissociative symptoms generally begins between 5 and 10 years of age with alters formed by age six. The disorder is most frequently seen in females and isn’t diagnosed until the 20s or 30s. There will be more alters as the child ages with more than 20 alters seen in adolescents, although the number will go down with treatment. Childhood abuse is the most common etiology, particularly sexual abuse as a child. The patients will often dress differently from one another and will have both sexual promiscuity and difficulty attaining an orgasm. Hearing voices is common as is referring to oneself as “we” rather than “I.” The goal for the treatment of patients with DID is integrated functioning. The patient must be viewed as a “multiple” that has identities that share the responsibilities of life. Switches can occur at any time and the therapist needs to deal with the alters’ often competing points of view. The different parts need to learn to be aware of one another and resolve the conflicts between them. Eliminating or ignoring entities is counterproductive to the therapeutic goal as this simply does not work. An intermediate goal is to achieve integration, where the identities can harmoniously coexist. Finally, fusion is a tertiary goal, in which there is a loss of subjective separateness. Final fusion involves the presence of a single unified self. Unification is another term for “final fusion” and represents the end of the therapeutic goals involved in treating DID patients. Not all patients can achieve nor do they want to achieve unification. Cooperation among the alters is a reasonable goal for some patients who will have reasonable degrees of functioning. 127 There are three phases to the individual psychotherapy used in the treatment of dissociative identity disorder. In phase one, there is the establishment of safety, reduction in symptoms, and stabilization. Phase two involves confronting and working through the traumatic memories. Phase three involves integration and rehabilitation. Besides the preferred treatment of individual psychotherapy, patients can participate in family systems therapy, cognitive therapy, clinical hypnosis, and creative arts therapy. It does not respond to medications unless there is coexisting anxiety and depression. DISSOCIATIVE AMNESIA (300.12) Dissociative amnesia or DA is one of the three specified dissociative disorders seen in DSM-V. There is a transient loss of recall memory in this disorder that can occur over a few seconds or a few years. This is almost always secondary to psychological trauma. It involves memory loss that is beyond that seen with typical forgetfulness. The patient may forget key details of what happened before or during a traumatic event but will remember other details. This usually arises out of childhood traumatic events but can be difficult to actually diagnose. In older individuals, it can stem from war trauma or stressful situations that involve extremes of emotions that the individual cannot cope with. There are brain abnormalities in the right temporo-frontal cortical area in individuals who have dissociative amnesia. The main criteria of dissociative amnesia, according to the DSM-V, include the following: • Inability to recall autobiographical memories about a traumatic event • Distress caused by the inability to remember the event • There is no physiological cause of the lack of memory • The disorder is not secondary to dissociative identity disorder • There is no substance use or abuse involved 128 Having suppressed memories can be harmful to the patient and sometimes requires treatment. The partial memory recall can lead to flashbacks and nightmares. It is often a comorbid state with PTSD and can lead to self-destructive or self-harming behaviors or aggression against others. Dissociative fugue is not a separate disorder in the DSM-V but is a subtype of dissociative amnesia. In dissociative fugue, the patient often leaves their home and assumes a new identity far from where they used to live. Daily life can trigger the person to dissociate more. The condition of DA can affect a person’s work-life, where they may fail to remember key aspects of their job. Relationships can suffer and families can be stressed by the depressed and confused state of the family member who has lost their memories. Friends and family can play an important role in helping the individual recover lost memories. Cues and storytelling with the help of a therapies can help recover memories without furthering dissociation. Relaxation can help as well. Some will improve with mindfulness therapy. The object of any treatment for dissociative amnesia is to reintegrate the memories and relieve the patient of fragmentation. The disorder is difficult to treat and most commonly spontaneously resolves however, it can take many years for this to occur. Treatment can, on the other hand, reduce the underlying symptoms, helping the patient decrease depressive and suicidal symptoms. The comorbidity of PTSD can be treated with therapy. The major treatment involves psychotherapy, which includes dream analysis and memory training in order to retrieve hidden memories. Cognitive-based therapies are the most effective at reducing the symptoms and improving memory recall. Dissociative fugue is fascinating to many people and is a subtype of dissociative amnesia in the DSM-V. These are people who change their identity and move to a new location after a traumatic event or accident. Once they are discovered and identified, they undergo a slow or spontaneous recovery, in which they gradually recover their lost memories and resume their regular daily activities. 129 DEPERSONALIZATION/DEREALIZATION DISORDER (300.6) These are actually two disorders that have been redefined as a single entity in the DSM-V as they have similar symptoms and a similar etiology. These people have ongoing or recurrent feelings of bodily or cognitive detachment from their environment or themselves. They maintain a connection to reality, which differentiates these patients from other dissociative disorders. The patient is distressed by this detachment and often feels robotic. Depersonalization involves viewing themselves from the outside or being “outside of themselves,” while derealization involves detachment from the environment and other people. The patient feels like they are in a dream. The prevalence of the disorder is seen in about 2 percent of the general population. It affects men and women the same and is felt to be an underdiagnosed illness. The onset of the disorder is at about 16 years of age (the mean age of onset). The major symptoms of depersonalization include the following: • Emotional detachment • Distortion of body image • Difficulty recognizing one’s own image in a mirror • Anesthesia of a body part or parts • Feeling like a spectator outside of the body The major symptoms of derealization include the following: • Feeling detached from one’s surroundings • Feeling that life events are unreal • Seeing objects as changing in shape, color, or size • Feeling like known people are strangers 130 • Feeling of being in an unfamiliar environment when this isn’t the case The patient may also feel like both of these symptom clusters are happening at the same time. The symptoms may be sporadic in nature or chronic. As a whole, these types of dissociative disorders are difficult to diagnose. This can be because there is a great deal of comorbidity with them, there is often a lack of information on early childhood trauma, and the patient may have difficulty recalling past unpleasant events in their lives. The DSM-V criteria include the following: 1. The presence of depersonalization and/or derealization 2. There are no other disorders or substances to account for the symptoms 3. The individual knows their experiences are not real and have intact reality 4. There is significant distress or social/occupational impairment There are no single causes for depersonalization/derealization disorder; however, there are often episodes of severe distress, depression, and panic attacks, and the misuse of drugs like hallucinogens and marijuana. The disorder often stems from childhood trauma especially emotional abuse or neglect. It can involve a history of seeing a severe accident or being assaulted or emotionally abused as an older person. Typical comorbidities linked to depersonalization/derealization disorder include PTSD, anxiety disorders, depression, avoidant personality disorder, borderline personality disorder, or obsessive-compulsive disorder. Things that must be ruled out as possible differential diagnoses include bipolar disorder, schizophrenia, PTSD, drug or alcohol abuse, medication use or medication withdrawal. People with this disorder are distressed by it and can have social or occupational impairment. The individual may have an inability to function normally in everyday tasks and in social situations. The dissociation can lead to anxiety, which feeds back and increases the symptoms. 131 There is no cure for the disorder but there can be treatment with psychotherapy and medications, which can be used together or separately. Psychotherapy can include counselling, cognitive behavioral therapy, grounding techniques, and psychodynamic therapy. There are a number of drugs that can be used, including tricyclic antidepressants, clomipramine, fluoxetine (an SSRI), lamotrigine (an anticonvulsant), and opioid antagonists that block the body’s response to endorphins and opioids. The prognosis is generally good with treatment. OTHER SPECIFIED DISSOCIATIVE DISORDER (300.15) Patients with this disorder have varying dissociative symptoms that don’t fit the diagnosis of any particular dissociative disorder. There is a loss of awareness of one’s surroundings or a lack of complete orientation to their surroundings. The patient may have a “dissociative trance,” in which they are unresponsive to outside stimuli. They may feel paralyzed as though things around them are blurry or surreal. There is a detachment of awareness of who the person is. This is especially seen in patients who’ve endured long periods of abuse, captivity, or torture. Other individuals with other specified dissociative disorder have an acute dissociative reaction to a severe stressor or trauma called the “syndrome of mixed dissociative symptoms.” These patients will experience amnesia of part of the event, a sensation of time slowing down, “tunnel vision,” and the feeling of being on an analgesic or anesthetic. There is a diagnosis of unspecified dissociative disorder, in which the patient has a dissociative event or condition that does not fit into the typical presentation of a known dissociative condition. The source may be unclear and things like a head injury after a head trauma or car accident can cause dissociation that may or may not be medical in origin. This is the diagnosis given when there is dissociation but no clearly defined dissociative disorder.