Dissociative Identity Disorder (multiple personalities)
The Dissociative Identity Disorder is characterized by the presence of two or more distinct states of personalities, which are called alternative identities. Each state has its own ways of perceiving, relating, and thinking towards itself and the environment.
At least two of these identities or personality states assume recurrently the control of the person’s behavior. In addition, each of them, when is in control, has absolutely no awareness of the others. The symptom that characterizes the Dissociative Identity Disorder is dissociative amnesia. The inability to remember important personal informations, facts and even traumatic events. Symptoms cause significant discomfort or impairment on important areas of functioning. It Can be detected by the individual or observed by other people. Dissociative Identity Disorder is a serious and chronic disease and can lead to invalidity and disability. It is often associated with depression and borderline personality disorder and has a high incidence of suicide attempts.
How does it manifest itself?
The distinctive feature of dissociative identity disorder is the presence of two or more distinct personality states or an experience of possession. When the states of alternative personalities do not manifest in an obvious way, the disease can be identified by two groups of symptoms
-sudden alterations or discontinuity in the sense of self and sense of agency: individuals can perceive the sensation to have suddenly become observers of themselves, or report to hear voices. They can suddenly observe strong emotions, impulses, and even speeches or other actions, without a personal sense of control (sense of agency). These emotions and impulses are often experienced as unpleasant and cause of upsetting. The alterations in the sense of self and the loss of personal agency can be accompanied by a feeling that attitudes, emotions and behaviors, or even their own body, are “not mine” or are “not under my control”.
-Recurrent dissociative amnesia: Gaps in recalling personal life events (periods of childhood or adolescence, important life events); Significant memory gaps of what happened during the day, or how to do their own work, how to use a computer, how to drive the car; the discovery of actions that they do not remember to have done. The so-called dissociative fugues are also frequent: they can suddenly find themselves in places without remembering at all how they arrived there.
Dissociative identity disorder (DDI). How frequent?
Dissociative Identity Disorder and dissociative disorders in general are not as rare as you might think. Clinical studies carried out in North America, Europe and Turkey have identified a percentage of the diagnosis of DDI between 1% and 5% of the generic patients admitted to psychiatric units, hospitalized adolescents, and in the programs for substance abuse, eating disorders, and obsessive-compulsive disorder.
Although the disorder is a relatively common pathology there is a certain difficulty among clinicians to diagnose it. This difficulty is linked to the lack of knowledge and education about dissociation, dissociative disorders and the effects of psychological trauma, as well as to clinical prejudice.
Many clinicians think that dissociative identity disorder is a rare disease with a florid and dramatic presentation.
In fact only a small percentage of people diagnosed with this disorder have such obvious symptoms. Instead of visibly showing distinct alternative identities, the typical patient with a Dissociative Identity Disorder presents a polysymptomatic mixture of dissociative symptoms characteristic of post-traumatic stress disorder (PTSD). The amnesia we talked about, the episodes of dissociative fugue, the confusion about life events. These are mixed into an array of other symptoms. To give examples, depression, panic attacks, substance abuse, somatoform symptoms (pains, paresthesias, etc…) and eating disorders. The importance of these last symptoms, often highly familial, leads the therapists to diagnose only these conditions instead of the DID.
When this happens, the patient may undergo a long and often ineffective treatment, erroneously addressed to the apparently non-traumatic symptomatology.
The causes of the missed diagnoses
Many professionals use standard diagnostic interviews, such as mental state examinations and scales for the measurement of anxious, depressive, psychotic symptoms etc… These instruments are not able to detect the presence of dissociative manifestations and the signals of a traumatic past. Furthermore, since patients rarely provide information about dissociative symptoms, the absence of a specific, focussed disassociation investigation prevents the clinician from accurately diagnosing the disorder. The majority of clinicians received in the past little or no formation on dissociation.
Happily today times have changed.
Dissociative disorders, a rediscovery
In the last 30 years, the diagnosis, evaluation and treatment of dissociative disorders have improved enormously. The result of increased clinical recognition of dissociative conditions, the publication of numerous scientific research and work on the subject, and the development of specific diagnostic tools. Publications on dissociative disorders have appeared in the international literature of at least twenty-six countries, including the United States, Canada, Puerto Rico, Argentina, the Netherlands, Norway, Switzerland, Northern Ireland, Great Britain, France, Germany, Italy, Sweden, Spain, Turkey, Israel, Oman, Iran, India, Australia, New Zealand, the Philippines, Uganda, China and Japan. These publications include a number of clinical cases and data collection; physiological, neurobiological and neurimaging (in vivo cerebral visualization) research; Discussion of the development of diagnostic tools; Descriptions of ongoing clinical trials, studies on the outcome of treatments, and descriptions of therapies.
These disclosures constantly provide evidence that dissociative identity disorder is a transcultural diagnosis, that is, regardless of the culture of belonging.
The origins of the disorder
Dissociative Identity Disorder is almost universally associated with a previous history of significant trauma, most frequently occurring during early childhood.
Potentially it is possible that having undergone invasive and painful medical procedures for a prolonged period may cause the onset of post-traumatic and dissociative phenomena, including the structure of a real DID. Many experts propose an evolutionary model and hypothesize that the development of identities is the result of the inability of traumatized children to develop a unitary sense of self. This is maintained through different behavioral states. In particular, the disorder is most likely to develop when the first traumatic exposure occurs before the age of 5 years.
Psychic trauma means exposure to an event that transcends the child’s mind processing capabilities. Trauma often occurs in the context of attachment relationships, in which the child is in a position of dependence and is forced to adopt extreme defense strategies, such as dissociation. Fragmentation and encapsulation of traumatic experiences are used to protect relationships with caregivers (albeit abusive) and to allow increased maturation in other areas of development. The theory of “structural dissociation of personality,” another etiological model, is based on Janet’s ideas and attempts to create a unique dissociation theory that includes DDI. This theory suggests that dissociation is the result of a basic failure of integration of cognitive systems and personality functions. Following the constant exposure to traumatizing events, the personality can divide into a “seemingly normal” part dedicated to the daily functioning and an “emotional part” dedicated to the defense. Defence in this context is linked to survival in response to life-threatening threats. Fight/Flight, freeze, feigned death. Not to the psychoanalytic notion of defense. Chronic trauma and/or neglect may lead to secondary structural dissociation and the emerging of separate emotional components of the personality.
The election therapy for the DID care is psychotherapy.
Pharmacological treatments can add support in cases where emotional stabilization is necessary. However they are aimed at a better implementing of psychotherapy.
The treatment aims to bring the patient to an integrated operation when possible.
A fundamental principle of the treatment of DDI patients is to determine greater communication between identities. In most patients DDI each identity seems to have its “own” perspective and a sense of “own” self, as well as a vision of the other parts as “not self”. The identity that has control usually speaks in first person and may not recognize other parts or be completely unaware of their existence.
The alternation between identities occurs in response to changes in emotional state or environmental needs. An activating event has the consequence that the emerging identity gains control. Because different identities have different roles, experiences, emotions, memories and beliefs, the therapist is constantly struggling with the competition between their points of view.
At the heart of a therapeutic process with DDI patients, there must be the idea of helping identities to know each other, accepting themselves as legitimate parts of the self and negotiating and resolving their conflicts.
For further information: GUIDELINES_DID_REVISED_2011