Dissociative Identity Personality Disorder (DPID)

What is this personality disorder?

The Dissociative Identity Disorder of Personality (DIDP) is a complex disorder that has been little studied and represents a challenge for clinicians. The complexity lies in part in the difficulty of identifying it. As a result, many cases are lost in anonymity.

Dissociative Personality Identity Disorder: what is it?

One of the first challenges that DIDP patients face in therapy is that they often receive incomplete or simply wrong diagnoses. Incomplete in the sense that they may be relevant with respect to one or more of the alter egosIncomplete in the sense that they may be relevant to one of the alter egos, while inadequate in the context of multiplicity.

Many people with Dissociative Personality Identity Disorder never seek psychological or psychiatric consultation. And when they do, they often receive the wrong diagnosis. This makes it impossible for them to get the help they need.

What is PDID?

Specialists in this disorder include Valerie Sinasona psychoanalyst and director of the Clinic for Dissociation Studies. She is the editor of the book "Attachment Trauma and Multiplicity" and in the introduction to it, she comments:

"Over the past decade I have counseled and treated children and adults, especially women, who have Dissociative Identity Disorder of Personality (DPID). There is a very significant gender bias in people with this condition. Male child victims of abuse are more likely to externalize their trauma, even though both sexes employ externalizing responses. Most of the children and adults I have evaluated have been misdiagnosed as schizophrenic, borderline, with an antisocial or psychotic disorder.... Despite the fact that the antipsychotic medication had little or no effect on them, that the voices they heard were coming from within and not from outside, and that they did not present with a disordered thinking about time and place except when in a trance state, despite all this, the mental health professionals did not perceive flaws in the diagnosis. In the face of professional confusion and social denial, some patients have managed to hide their multiplicity when accused of inventing it. In response to the key question concerning the small number of children presenting with severe dissociative states, some patients confirmed the negative responses to their childhood confessions that led them to hide their symptoms. These children were told that they would grow out of it and that it was a phenomenon of imaginary friends" (2002 p. 5).

Dissociation

The purpose of the concept of dissociation refers to the process of encapsulating or separating the memory or emotion that is directly associated with the trauma from the conscious self. Dissociation is a creative way of keeping something unacceptable out of sight. Dissociative Personality Identity Disorder is a way the internal system creates to protect secrets and continually learns to adapt to the environment. It is a survival mechanism. It also promotes and maintains attachment to the abuser. It allows, at the mental level, some conflicting emotions to be kept in separate compartments.

More specifically, dissociation involves a wide variety of behaviors that represent lapses in cognitive and psychological processing.. The three main types of dissociative behavior that have been recognized are: Amnesia, absorption, and depersonalization.

• The dissociative amnesia involves suddenly finding oneself in a situation or being confronted with evidence of having performed actions that the person does not remember.
• The absorption involves becoming so involved in what is being done that the person forgets what is going on around him or her.
• The depersonalization refers to experiencing events as if the individual were an observer, disconnected from the body or feelings.

Causes

North et al. (1983; cited by Sinason p. 10) found that this condition was not only linked to a high percentage of childhood sexual abuse, but also to a 24-67% occurrence of sexual abuse in adulthood, and 60-81% of suicide attempts.

It is clear that TIDP is an important aspect of the cluster of trauma-induced conditions. In the USA, in a sample of 100 patients with TIDP, 97% of them were found to have experienced major childhood trauma. 97% of them had experienced major trauma in childhood and almost half had witnessed and almost half of them had witnessed the violent death of someone close to them. (Putman et al. 1986; cited by Sinason p. 11).

Until very recently, it has been extremely difficult to document childhood cases of TIDP. Although there are those who argue that this does not mean that they do not exist. The same is true for adolescent cases, and it is only adult cases of TIDP that receive the support of the scientific community.

Richard Kluft believed that his efforts to trace the natural history of TIDP had little success. His attempts to find childhood cases were an "unmitigated fiasco". He described the case of an 8-year-old boy who appeared to manifest "a number of developed personality states" after witnessing a situation in which someone almost drowned in water, and having been physically abused. However, he realized with other colleagues that his field of vision was too narrow. He noticed that Gagan and MacMahon (1984, cited by Bentovim, A. p. 21) described a notion of an incipient multiple personality disorder in children; they raised the possibility of a broader spectrum of dissociative phenomenology that children could manifest.

Diagnostic criteria for BPID

The DSM-V criteria criteria specify that BPID manifests with:

• The presence of one or more distinct identities or personality states (each with its relatively stable perceptual patterns, in relation to, and thinking about, the environment and the self.
• At least two of these identities or personality states recurrently assume control of the person's behavior.
• An inability to recall important personal information that is too widespread to be explained by ordinary forgetfulness and that is not due to the direct effects of a substance (e.g., loss of consciousness or chaotic behavior during alcohol intoxication) or a general medical condition (e.g., complex partial seizures).

Guidelines for diagnosis and treatment

Regardless of the diagnosis, if dissociation is present, it is important to explore what role it plays in the patient's life.. Dissociation is a defense mechanism.

It is important for the therapist to discriminate dissociation and to talk about defense mechanisms as parts of a process. The therapist can then accompany the patient in exploring the reasons why he or she may be employing this mechanism as a defense. If the therapist addresses the issue of dissociation as early and as there is some indication of it, the diagnosis will come more easily. Using the Dissociative Experiences Scale (DES) or the Somato-Tomorphic Dissociation Questionnaire (SDQ-20) can help determine the degree and role dissociation plays in the person's life. (Haddock, D.B., 2001, p.72)

The International Society for the Study of Dissociation (ISSD) has developed general guidelines for the diagnosis and treatment of BPID. It states that the foundation for a diagnosis is a mental status examination that focuses on questions related to dissociative symptoms. The ISSD recommends the use of instruments for dissociative screening, such as the DES, the Dissociative Disorders Interview Schedule (DDIS), and the DSM-IV Structured Clinical Interview for Dissociative Disorders.

The DDIS, developed by Ross, is a highly structured interview that covers topics related to the TIDP diagnosis as well as other psychological disorders. It is useful in terms of differential diagnosis and provides the therapist with mean scores in each subsection, based on a sample of TIDP patients who answered the inventory. The SCID-D-R, developed by Marlene Steinberg, is another highly structured interview instrument used to diagnose dissociation.

An important aspect of Steinberg's work consists of the five core dissociative symptoms that must be present to diagnose a TIDP or TIDPNE (non-specific) person. These symptoms are: dissociative amnesia, depersonalization, derealization, identity confusion and identity disturbance.

TIDP is experienced by the dissociator as identity confusion (whereas the non-dissociator typically experiences life in a more integrated way). The TIDP experience is comprised of the dissociator frequently feeling disconnected from the world around them, as if they are living in a dream at times. The SCID-D-R helps the clinician identify specific aspects of this story.

Diagnosis

In any case, the therapist's basic components related to the diagnostic process include, but are not limited to, the following:

A thorough history

An initial interview that may last between 1 and 3 sessions.

A special emphasis on family of origin issues, as well as psychiatric and physical history.. The therapist must pay attention to memory gaps or inconsistencies found in the patient's accounts.

Direct observation

It is helpful to make notes regarding the amnesia and avoidance that is occurring in the session. It is also necessary to appreciate changes in facial features or voice quality, in case it seems out of context to the situation or what is being discussed at the time. Notice extreme sleepiness or confusion that interferes with the patient's ability to follow the therapist during the session (Bray Haddock, Deborah, 2001; pp. 74-77).

Review of dissociative experiences

If dissociation is suspected, a screening tool such as the DES, DDIS, SDQ-20, or SCID-R could be used to gather more information.

Note symptoms related to amnesia, depersonalization, derealization, identity confusion, and identity disturbance before diagnosing TIDP or TIDPNE.

Differential diagnosis to rule out specific disorders

One can start by considering the above diagnoses. That is, taking into account the number of diagnoses, how many times the patient has been treated, goals achieved in previous treatments. Previous diagnoses are taken into consideration even if they are not used, unless they currently meet DSM criteria.

Then compare the DSM criteria with each disorder that has dissociation as part of its makeup and diagnose TIDP only after observing the change in alter egos.

Inquire whether substance abuse and eating disorders are present. If dissociation is suspected, using a screening tool such as CD or ED can provide further insight into the function of the dissociation process.

Confirmation of diagnosis

If dissociation is confirmed, again by comparing the DSM criteria for possible diagnoses and the diagnosis of TIDP, only after observing the relay of alter egos. Until then, the most appropriate diagnosis will be Dissociative Identity Disorder Personality Nonspecific (DPIDPNOS) or Posttraumatic Stress Syndrome (PTSD).

Bibliographic references:

• Bray Haddock, Deborah, 2001. The dissociative identity disorder. Sourcebook. McGrow-Hill Publishers, New York.
• Fombellida Velasco, L. and J.A. Sánchez Moro, 2003. Multiple personality: a rare case in forensic practice. Cuadernos de Medicina Forense. Seville, Spain.
• Orengo García, F, 2000. Prevalencia, diagnóstico y abordaje terapéutico del trastorno de identidad disociativo o trastorno de personalidad múltiple. www.psiquiatria.com
• Rich, Robert, 2005. Got parts?: An insider's guide to managing life successfully with dissociative identity disorder. ATW and Loving Healing Press. USA.
• Sinason, Valerie, 2002. Attachment, trauma and multiplicity. Working with Dissociative Identity Disorder. Routledge, UK.