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Dissociative Disorders are defined as disruptions or disturbance of the normal integration of
fundamental human characteristics of normal psychological functioning. Consciousness, memory,
identity, emotion, perception, body representation, motor control and behavior are all affected in
dissociation. Some of the core features in dissociation include amnesia, depersonalization,
derealization, identity confusion, and identity alterations. It is apparent when one evaluates all the
features of this disorder, that this is a spectrum with varying levels of severity. Dissociative identity
disorder (DID) is the most pervasive condition of all dissociative disorders
Dissociative identity disorder (DID) is defined in DSM-5 as the presence of two or more
distinct personality states or an experience of possession and b) recurrent episodes of amnesia.
Individuals diagnosed with DID experience a) recurrent, inexplicable intrusions into their conscious
functioning and sense of self, b) alterations in self of self, c) odd changes of perception and d)
intermittent functional neurological symptoms.
Once called, Multiple Personality Disorder, the hallmark feature of this disorder is the
multiple personality states. Long-term, severe child sexual abuse; and to a lesser extent, physical
abuse, in combination with poor or non-existent social/family support systems seem to correlate to
the development of DID. Although abuse is a predisposing factor in nearly all cases of DID, abuse is
not predictive of DID,(Rind and Tromovitch, 1997) those with secure attachments and family
support seem to have more protective mechanisms and resilience against psychopathy and further
substantiate the importance of social intervention. (Korol, 2008). Dissociation among women in the
general population who experienced possession and altered self, are believed to be related to
authoritarian and rigid parenting styles. (Sar, 2013).
Some of the features from patients diagnosed with DID include chronic suicidal ideation,
sexual promiscuity (often times in combination with sexual dysfunction) and thought disorders
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which may include perception dysfunction. This patient population may mistakenly report
hallucinations with a complex visual quality, which is most likely a remembrance of an experience
with an alter rather than a hallucination. Patients may refer to themselves in the third person, and can
often be of opposite gender. Patients may have long periods in which they cannot account for, in the
form of blackouts, time loss, or trance experiences; and as a result, may have inconsistent
employment histories. Finally, as with any physiological manifestation, genetics, and environment
may also play a role in the development of DID.
Controversy and skepticism surround the etiology and diagnosis of DID for several decades
even the face of Randomized, Double-Blind, Placebo-controlled, Trials. The curriculum in Medical
School and post-graduate training typically excludes training on the diagnosis of dissociative
disorders, leaving clinicians ill-prepared for this patient population. According to a survey of
therapists experienced in treating DID patients, 78% reported that they experienced intense
skepticism from colleagues, specifically due to the decline in interest in dissociation, under
appreciation/lack of awareness of the prevalence of individuals with dissociative ability, and finally,
misconceptions or ignorance as to the clinical presentation of DID patients. Additionally, nearly
50% of those respondents reported extreme skepticism and repeated acts of harassment against the
patient and/or therapist (Dell, 1988) that have occurred and still occurs today.
In general, practitioners who accept the validity of DID as a diagnosis believe dissociation is
a purposeful form of coping through an elaborate form of denial in which someone else is
experiencing the event. This occurs quite often in early childhood, coinciding with imaginary friends
(Watkins, 1998). DID is a chronic complex of dissociative symptoms and therefore, has
understandable challenges in diagnoses and treatment. Practitioners who are poorly trained have a
tendency to limit therapy to memory recovery, which has been shown to cause worsening of
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symptoms (Loewenstein, 1991). As one would expect, patients who have been diagnosed with DID
have significant trust and rejection issues. Long term therapy, typically in an outpatient setting on a
weekly or bi-weekly basis is not uncommon.
The diagnostic interview should address experiences of amnesia, posttraumatic, pseudo-
psychotic and passive-influence symptoms, childhood abuse or trauma (Loewenstein, 1991). These
traumas have been defined not as hidden or suppressed, but unsymbolized. Unsymbolized thinking is
a form of inner speech or a vague image and acknowledging this type of thinking in a DID
population may have substantial benefit (Stern 1997, Hurlburt, 2008) but may not occur early in
therapy. As the clinical interview progresses, symptoms of dissociation may become apparent in the
form of spontaneous trances, age-regression, or frank switching. Collecting as much information as
possible of alter personalities will be critical in the treatment process.
Scientific literature regarding a patient’s altered states report differences in respiratory rate,
muscle tone, patterns of neural network activation and cerebral blood flow (Putnam, 1994).
Interestingly, certain alternate identities may follow patterns of arrival; coming out when preceded
by specific others or followed by the presence of specific others (Putnam, 1994). Each alternate
identity may have their own memory, experiences and sense of ownership and thoughts (Watkins,
1998). The number of alters is not believed to be of concern because most often, the alters usually
collapse as treatment moves forward (Kluft, 2006).
During treatment interventions, it is common for several alters to go away and not return,
especially when the personality state was created to defend against an abuse or injury that has been
integrated or resolved. It should not be the goal of therapy to obliterate alters, in fact, quite the
opposite is true. Integration of the alters, who were created to protect, are an important element to
the goal of therapy; creating a more adaptive personality structure. Engagement with alters has been
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recommended to take place early and often in treatment. Related to this discussion, it is important to
create an atmosphere that is comfortable for the patient in order to allow the frank switching and
spontaneous trances during therapy.
When this occurs, the therapist can use this information as part of the clinical assessment. If
this does not occur, failure to stabilize, exacerbation of dissociative symptoms and decompensation
of the patient with increasing difficulties with safety and deterioration of day-to-day functioning may
occur (ISSTD, 2011).
The majority of the medical community may still need more reproducible multi-centered,
double-blind, randomized, placebo-controlled studies to reduce controversy and aid in the
determination of definitive treatment strategies. Acceptance of this diagnosis needs to take place.
when one considers the plethora of data available. A recent review of the literature (Brand 2013)
using case studies, case series, and anecdotal patient reviews from therapists with a high degree of
experience in treating DID patients, has gleaned specific recommendations that may be useful for
this complex, trauma-based disorder.
Experts agree that emotional regulation is critical, embracing all alters early and often is an
essential tool of treatment, a modified and patient-specific exposure or abreaction techniques may be
necessary when balanced with core, foundational interventions and in the final stages of therapy,
current and future life issues, such as engaging in healthy relationships and meaningful activities
should be the dominant focus. Even after one considers the lack of controlled trials, the danger in
depriving DID patients treatment is certainly more harmful.
The expanding interest in neurobiological research on brain function may offer additional
insight into treatment for patients diagnosed with DID. Early research has been devoted to hypo-
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perfusion of the orbitofrontal region of the brain, proposed to be affected by developmental trauma
in early life (Shore, 2003). This and other studies including SPECT, MRI, fMRI and PET may offer
practitioners additional therapeutic options in the near future.
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Citations:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed). Washington, DC: Author.
Brand, B. L., Classen, C. C., Zaveri, P., & McNary, S. (2009). A review of dissociative disorders
treatment studies. Journal of Nervous and Mental Disease, 197, 646-654.
Brand, B. L., McNary, S. W., Myrick, A. C., Classen, C. C., Lanius, R., Loewenstein, R. J., et al.
(2013). A longitudinal naturalistic study of patients with dissociative disorders treated by
community clinicians. Psychological Trauma: Theory, Research, Practice and Policy, 5, 301-308.
Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., et al.
(2012). A survey of practices and recommended treatment interventions among expert therapists
treating patients with dissociative identity disorder and dissociative disorder not otherwise specified.
Psychological Trauma: Theory, Research, Practice and Policy, 4, 490-500.
Carlson, E. B., & Putnam, F. W. (1993). An update on the Dissociative Experiences Scale.
Dissociation: Progress in the Dissociative Disorders, 6, 16-27.
Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M. J., Loewenstein, R. J., Cardena, E., et al.
(2012). Evaluation of the evidence for the trauma and fantasy models of dissociation. Psychological
Bulletin, 138, 550-588.
Dell PF. Professional skepticism about multiple personality. J Nerv Ment Dis. 1988; 176:528–531.
Fine, C G., (1999). The tactical-integration model for the treatment of dissociative identity disorder
and allied dissociative disorders, Am J Psychotherapy, 53(3) 361-76.
Hurlburt R.T., Akhter S., (2008) Unsymbolized Thinking. Conscious Cognition 17(4), 1364-74.
International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating
dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12, 115-
187.
Kluft R.P., (2006), Dealing with alters: a pragmatic clinical perspective. Psychiatric Clin North Am,
29(1) 281-304.
Korol, S., (2008), Familial and social support as protective factors against the development of
dissociative identity disorder, J Trauma Dissociation, 9(2):249-67.
Loewenstein RJ, (1991). An office mental status examination for complex chronic dissociative
symptoms and multiple personality disorder, Psychatr Clin North Am, 14(3) 567-604.
8. Dissociative identity Disorder Page 8
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Reinders, A. A. T. S., Nijenhuis, E. R. S., Quak, J., Korf, J., Haaksma, J., Paans, A. M. J., et al.
(2006). Psychobiological characteristics of dissociative identity disorder: A symptom provocation
study. Biological Psychiatry, 60, 730-740.
Reinders, A. A. T. S., Willemsen, A. T. M., Vos, H. P. J., den Boer, J. A., & Nijenhuis, E. R. S.
(2012). Fact or factitious? A psychobiological study of authentic and simulated dissociative identity
States. Plos One, 7, e39279-e39279. PMID: 22768068
Sar V, Alioglu F, Akyuz G., (2013) Experiences of possession and paranormal phenomena among
women in the general population: are they related to traumatic stress and dissociation. J Trauma
Dissociation, 15(3), 303-18.
Shore A., (2003). The experience-dependent maturation of a regulatory system in the orbital-
prefrontal cortex and the origin of developmental psychopathy. Norton NY: 5-35.
Stern, D.B. (1997). Unformulated experience: from dissociation to imagination in psychoanalysis.
Mahway, NJ: Analytic Press.
Watkins J.G. (1998). The management of malevolent ego states in multiple personality disorder.
Dissociation, 1(1), 67-71.
