Tamara McKlveen

September 5, 2013
CNS6018 Psychopathology
Dr. Laurence
DISSOCIATIVE IDENTITY DISORDER
Dissociation can be described on a spectrum; from mild
to severe, from temporary to chronic
Dissociation occurs when a persons psyche becomes
fragmented; the parts of the psyche are all there, but do
not function together cohesively
Sense of involuntariness feel that their thoughts,
feelings, memories, and behaviors do not belong to them
Loss of functions: dissociative amnesia, time distortions,
alienation from self or body, alienation from surroundings
Intrusions: Flashbacks, out of the blue impulses,
unexplained pain or sensations with no physical cause
Changes in awareness: Not being present, spacing out,
being very forgetful and losing track of time, inability to
concentrate and pay attention, hyper-absorption in an
avoidance activity, day dreaming, automatic driving
Now imagine the experience of dissociation becomes so
intense that we not only forget who we are, but begin to
think we are someone else

WHAT IS DISSOCIATION?
Disruption of identity
characterized by two or more
distinct personality states. This
may be described in some
cultures as an experience of
possession.
Recurrent gaps in the recall of
everyday events, important
personal information, or traumatic
events inconsistent with ordinary
forgetting
The symptoms cause clinically
significant distress or impairment
in social, occupational, or other
important areas of functioning
The disturbance is not a normal part of
a broadly accepted cultural or religious
practice (ie in children the symptoms
are not better explained by an
imaginary playmate or fantasy play)
The symptoms are not attributal to the
physiological effects of a substance (ie
alcohol or drug use) or another
medical condition (ie complex partial
seizures)
DSM-5 DIAGNOSTIC CRITERIA
Patients with DID do not typically present
to therapy with complaints about their
identity or sense of self. They are
usually seeking help for other problems:
depression, anxiety, sleep problems,
substance abuse, self-injury, or
relationship problems.
DID is typically not seen in childhood;
they are more likely to present in overlap
and interference among mental states
with symptoms related to discontinuities
of experience
One study showed that 95% of DID
cases involve extreme cases of
childhood physical and sexual abuse.
Other severe traumas such as witnessing
horrific events during a war, terrorism,
and surgical procedures are also linked
Some studies suggest that there is a
developmental window of 9 years old.
Trauma occurring after age nine can
result in severe PTSD, but will typically
not develop into DID
Ongoing abuse, later life
retraumatization, comorbid mental
disorders, severe medical illness, and
delay in appropriate treatment are
associated with poorer prognosis
Overt changes in identity may be
triggered by removal from the
traumatizing situation, having children
that reach an age where one was
abused, later traumatic events even if
they are not the same kind of trauma, the
death or fatal illness of an abuser

DID DEVELOPMENT AND COURSE
Americans with DID have, on average, about 15 distinct
identities
Based on case study evidence, females with DID
outnumber males at a ratio of 9:1
Adult males with DID tend to deny symptoms and
histories of trauma, which may result in false negative
diagnosis
Males typically present with more criminal or violent
behavior than females; triggers include combat, prison
conditions, and physical or sexual assault
Females typically present with acute dissociative states
(flashbacks, amnesia, fugue, conversion symptoms,
hallucinations, and self-mutilation
Over 70% of outpatients with DID have attempted
suicide, usually more than once. Suicide assessment
may be complicated by amnesia states

GENDER AND LETHALITY CONSIDERATIONS
Note that in the DSM-5 Dissociative Disorders
are categorized between Trauma and Stressor
Related Disorders and Somatic Disorders
Other Specified Dissociative Disorder
Other specified dissociative disorder will not meet
Criterion A and are not accompanied by recurrent
amnesia
Major Depressive Disorder
Level of depression experienced in DID does not meet
Criterion for MDD. Depressed mood fluctuates due to
presence of alternate identities
Psychotic Disorders
DID symptoms easily mistaken as psychotic. Individuals
with DID will do not have delusional explanations for
phenomenon and often describe symptoms in a
personified way (ie. I feel like someone else wants to
talk with my lips)
Substance/medication induced disorders
Does the substance etiologically related to symptoms?
Personality Disorders
In DID Personality style is not persistent
Compared to patients with BPD, patients with DID show
greater social interest, self -reflective capacity, perceive more
accurately and think more logically
Conversion Disorder
Absence of identity disruption
Seizure Disorder
Normal EEG findings
Bipolar Disorder
Shifts in mood will be very rapid compared to those
seen in Bipolar Disorder; moods associated with specific
personalities
Posttraumatic Stress Disorder
Symptoms are similar and can be comorbid. Look
for symptoms that are not characteristic of PTSD or
DIFFERENTIAL DIAGNOSIS PGS 296-297
Factitious Disorder and Malingering
Malingerers tend to over report well-publicized symptoms (ie.
amnesia) while underreporting more subtle symptoms
(depression). Malingers seem to enjoy having the disorder
while true sufferers deny symptoms. Malingerers also tend to
establish limited, stereo-typed identities (personalities who are
all good or all evil) to get away with crimes
Case Study: Kenneth Bianchi, the Hillside Strangler
In 1983 he was convicted, with Angelo Buono, of brutally raping
and murdering at least 10 girls in Los Angeles, California
Tried to use DID as his defense. After being hypnotized claimed
another man, Steve, committed the acts
Upon further clinical evaluation, Dr. Martin Orne discovered that
Bianchi was faking symptoms. (When Orne suggested a
diagnosis of DID required three distinct personalities, a new
personality suddenly emerged). Orne confirmed no history of
symptoms prior to arrest and investigators also found
psychological textbooks in Bianchis rooms
DIFFERENTIAL DIAGNOSIS
Case study evidence suggests personal
differences in those who develop and do not
develop DID
Patients who do develop DID may be less
resilient, more prone to anxiety and
depression than others
Persons with DID are often highly suggestive
Easily hypnotized and reactive to
suggestions
About 50% of patients with DID report
extensive imaginary play in childhood,
including the presence of imaginary friends
About 6% of patients with seizure disorders report
out of body experiences, and about 50% of
patients with temporal lobe epilepsy display
dissociative symptoms, including alternate
identities or identity fragments
Symptoms of DID are often markedly increased in
times of sleep deprivation and stress
Studies show patients who dissociate show
decreased skin reactivity
Case Study: Jonah
Medical examinations revealed that
Jonahs different personalities had
different EEG responses to
emotionally laden words
In another famous case, Eve Black
(the subject of the book and movie The
Three Faces of Eve), one personality
demonstrated a transient
microstrabismus that the other
personalities did not have
The Controversy of DID
http://www.youtube.com/watch?v=gfiB82OUXf0
BIOLOGICAL FINDINGS IN DID
We MUST consider cultural background
when diagnosing DID
Many features of DID can be influenced
by an individuals cultural background
In settings where normative possession
is common (rural areas in the developing
world, certain religious groups in the
United States and Europe) the
fragmented identities may take the form
of spirits, deities, demons, animals, or
mythical figures.
We differentiate cultural occurrences
from clinical significance if the symptoms
are involuntary, distressing,
uncontrollable, persistent, create conflict
in home, work, or social settings, and
when they manifest at times and places
that violate the cultural norms
CULTURAL CONSIDERATIONS
Clinical Treatment typically involves three distinct phases
Stage 1
Emphasis on skill building and maintenance of safety
from danger to self and others
Work on emotion regulation, impulse control,
interpersonal effectiveness, grounding, and
containment of intrusive material
Cognitive therapy to address trauma based distortions
Stage 2
Use of carefully monitored exposure techniques
balanced with core, fundamental interventions
Stage 3
Seek to integrate the personalities.
Evidence suggests only 2 percent of patients with DID
successfully integrate
Good health practices
improve course of symptoms
and treatment outcomes
Improve sleep habits
Establish a healthy daily
structure
Make appropriate time
for free time and
relaxation
Keep up with good
physical health
Develop healthy eating
habits
TREATMENT
REFERENCES
American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5
th
ed.).
Washington, DC: American Psychiatric Publishing.
Barlow, D., & Durand, V. (2012). Abnormal psychology: An integrative approach. (6
th
ed.). Washington DC:
Wadsworth Cengage Learning.
Boon, S., Steele, K., & Van der Hart, O. (2011). Coping with trauma-related dissociation: Skills training for
patients and therapists. New York, NY: W.W. Norton and Co.
Brand, B. L., Armstrong, J. G., Loewenstein, R. J., & McNary, S. W. (2009). Personality differences on the
Rorschach of dissociative identity disorder, borderline personality disorder, and psychotic inpatients.
Psychological Trauma: Theory, Research, Practice, and Policy, 1(3), 188-205.
doi:http://dx.doi.org/10.1037/a0016561
Brand, B. L., Myrick, A. C., Loewenstein, R. J., Classen, C. C., Lanius, R., McNary, S. W., . . . Putnam, F.
W. (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(5), 490-500. doi:http://dx.doi.org/10.1037/a0026487
Kong, L. L., Allen, J. J. B., & Glisky, E. L. (2008). Interidentity memory transfer in dissociative identity
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