Dissociative Identity Disorder

Overview

Definition

Dissociative identity disorder (DID), formerly known as multiple personality disorder, is a psychiatric condition characterized by the presence of ≥ 2 distinct alternating personality states that control a person’s behaviors and thoughts. While dominant, a personality is usually unaware of events that occurred during other personality states.

Epidemiology

• Rare condition; prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in the United States: approximately 1%
• Women affected more than men
• Main risk factors are childhood sexual and physical abuse Physical Abuse Violence inflicted on an individual through physical contact. Child Abuse and psychogenic trauma.
• Comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus include:
  • PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD)
  • Depression
  • Substance use disorders 
  • Somatoform conditions
  • Personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A Personality Disorders—borderline personality and avoidant personality

Etiology

• Trauma model:
  • Early childhood trauma or abuse might lead to splitting Splitting Defense Mechanisms off personalities as a way to cope with the trauma.
  • 85%–97% of those with DID report history of severe childhood trauma. 
• Sociocognitive model:
  • Proposed that patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship learn to construe themselves as multiple selves. 
  • Symptoms of DID are believed to be absorbed by patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship through representations of DID in movies, books, and other media.

Diagnosis and Clinical Features

Diagnosis

• Careful history taking, especially with multiple longitudinal assessments, as well as history from multiple sources, is the hallmark of correct diagnosis.

• Clinical diagnosis through meeting specific criteria:
  • Presence of  ≥ 2 distinct personality states
  • Recurrent memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment gaps (in everyday events, important personal information, and/or traumatic events)
  • Disruption involves marked discontinuity in sense of self and sense of agency.
  • Accompanied by related alterations in affect, behavior, consciousness, memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment, perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment, cognition, and/or sensorimotor functioning
  • Changes are observed by others or reported by patient.
  • Symptoms cause significant impairment.
• Exclusion:
  • The disturbance is not a normal part of a broadly accepted cultural or religious practice.
  • Substance use (alcohol), medical conditions ( seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures), and other psychiatric conditions must be ruled out.

Clinical features

• Depersonalization Depersonalization State in which an individual perceives or experiences a sensation of unreality concerning the self or the environment; it is seen in disorders such as schizophrenia, affection disorders, organic mental disorders, and personality disorders. Depersonalization/Derealization Disorder: sense of detachment from self 
• Derealization Derealization Derealization is a persistent subjective sense of detachment or unreality of the surrounding world often described by the patient as unreal, dreamlike, foggy, lifeless, or visually distorted reality. Depersonalization/Derealization Disorder: sense of detachment from one’s surroundings 
• Trance state: narrowing of awareness of immediate surroundings
• Self-alteration: sense that a part of one’s self is markedly different from other parts of one’s self
• Amnesia and gaps in memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment

Management and Prognosis

Management

• Main goal is to promote safety and reduce severity of symptoms. Physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship must mitigate the high risk of self-harm Self-harm Psychiatric Assessment for those with DID.
• Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:
  • Most widely used approach 
  • Goal is to help patient tolerate past trauma.
  • Also may include other behavioral therapy:
    • Cognitive therapy
    • Eye movement desensitization and reprocessing Eye movement desensitization and reprocessing A technique that induces the processing of disturbing memories and experiences, by stimulating neural mechanisms that are similar to those activated during rem sleep. The technique consists of eye movements following side-to-side movements of the index and middle fingers, or the alternate tapping of the hands on the knees. This procedure triggers the processing of information, thus facilitating the connection of neural networks. Posttraumatic Stress Disorder (PTSD) (EMDR)
    • Hypnosis Hypnosis A state of increased receptivity to suggestion and direction, initially induced by the influence of another person. Anesthesiology: History and Basic Concepts 
• Group therapy Group therapy A form of therapy in which two or more patients participate under the guidance of one or more psychotherapists for the purpose of treating emotional disturbances, social maladjustments, and psychotic states. Psychotherapy: more effective in carefully structured group composed of only with patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with DID 
• Pharmacotherapy:
  • Medication usually reserved for comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus (e.g., mood disorders or PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD))
  • Drug-assisted interviewing:
    • Aim is disinhibition to help the patient speak more freely
    • Drugs used in drug-assisted interviewing include barbiturates Barbiturates A class of chemicals derived from barbituric acid or thiobarbituric acid. Many of these are gaba modulators used as hypnotics and sedatives, as anesthetics, or as anticonvulsants. Intravenous Anesthetics and benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

• Dissociative identity disorder is a chronic illness and has an incomplete recovery.
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with earlier age at onset tend to have a poorer prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas.
• Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with undiagnosed or untreated DID are at higher risk of self-harm Self-harm Psychiatric Assessment and suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide.

Differential Diagnosis

• Borderline personality disorder Borderline Personality Disorder A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Cluster B Personality Disorders: a cluster B personality disorder marked by splitting Splitting Defense Mechanisms, self-harm Self-harm Psychiatric Assessment, chronic feelings of emptiness, outbursts, and inability to sustain relationships. Individuals with borderline personality disorder Borderline Personality Disorder A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Cluster B Personality Disorders have difficulties in handling everyday stresses, and their behavior can lead to serious issues with relationships and work. The persistent dysfunction in mood and interpersonal relationships found in borderline personality disorder Borderline Personality Disorder A personality disorder marked by a pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts. Cluster B Personality Disorders is not as prevalent in those with DID because of the variability in personality style. 
• PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD): psychiatric disturbance seen after experiencing a life-threatening event. Symptoms last > 1 month and involve reexperiencing the event as flashbacks or nightmares, avoiding reminders, irritability, hyperarousal, and poor memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment and concentration. In those with DID, there are dissociative symptoms that are not related to or arising from PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD), such as amnesia of nontraumatic and normal everyday events. 
• Malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering: not a medical disorder, but rather the behavior of an individual. Malingering Malingering Malingering is not a medical disorder, but a behavior of an individual. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients may either invent new ailments or exaggerate current symptoms. Malingering is characterized by the intentional falsification of symptoms for an external benefit. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship may either invent new ailments or exaggerate current symptoms. Those who falsify DID often have amnesia for socially unacceptable behaviors and exaggerate their symptoms in the presence of others. 
• Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia: chronic mental health disorder that is characterized by positive symptoms (delusions, hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia, and disorganized speech or behavior) and negative symptoms (flat affect, avolition Avolition Lack of initiative. Schizophrenia, anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia, poor attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment, and alogia Alogia Poverty of speech. Schizophrenia). Schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia is associated with a decline in functioning lasting > 6 months. Those with DID may experience similar alterations in realities; however, these are often experienced in a personified way (from the viewpoint of another personality).