Dissociative Identity disorder (DID), also known as multiple personality, is a standout amongst the most interesting conundrums in the field of psychology. This condition, with its extensive and tartan past, has been to some degree disputable (Forrest, 2001, p. 260). A budding body of literature is currently unearthing the basis and processes involved in DID, yet much is still obscure about the working of the psychological processes, particularly the state of mind and memory. It is against this backdrop that mental health experts do not have a common position regarding the effective diagnosis and treatment of dissociative identity disorder (Dorahy, Middleton & Irwin, 2004, p. 93).
In many cases, dissociative identity disorder occurs when a person experiences a disruption in his/her normally synchronized functions of identity, memory and consciousness of the immediate surroundings. In other words, the thoughts and feelings of a person no longer work in harmony (Forrest, 2001, p. 260). A person suffering from dissociative identity disorder may experience intense emotions, but fail to remember the cause of these emotions (McDonagh, 2005, p. 516).
According to the American Psychiatric Association (2000, p. 6), personality is defined as an entity that demonstrates an exceptional pattern of thought, discernment and relational style that entails both the environment and self. What is more, the personalities must demonstrate a pattern of manipulating the behavior of the individual.
Dissociative identity disorder is also characterized by abnormal and extensive loss of memory relating to personal information. Therefore, different prognoses usually overlook the adverse effects of medical conditions and chemical substances. For this reason, it is recommended that proper DID diagnosis should be done to differentiate real symptoms from imaginary play (American Psychiatric Association, 2000, p. 7).
Etiology of Dissociative Identity Disorder
Even though dissociative Identity Disorder has been included in the diagnostic and statistical manual of mental disorders, there is still no common ground as regards its diagnosis and therapy (American Psychiatric Association, 2000, p. 3). There has been a substantial argument regarding DID as a psychological disorder and a number of experts are still not sure as to whether DID is an authentic psychological issue (Boysen & Vanbergen, 2013, p. 6).
The contentions surrounding this issue, its cause and unclear diagnosis can last for a long time due to insufficient scientific evidence. There are two etiological theories of this disorder, that is, trauma-linked theory and non-trauma-linked theory.
The trauma-linked theory (Grilo, 2005), also referred to as the posttraumatic theory (Gleaves, 1996, p. Gleaves, 1996, p. 45) links DID to a number of factors, which include disjointed attachment, absence of distress-regulation, extreme emotional desertion, and psychological, physical and/or sexual exploitation during the early stages of life (McDonagh, 2005, p.517; Friedl & Draijer, 2000, p. 1012; Forrest, 2001, p. 272; Boysen &Vanbergen, 2013, p. 6). Based on this theory, dissociation is a personal defensive mechanism that is employed by the ill-treated child to deal with devastating and unpreventable cruelty and neglect.
This view is seconded by the findings of a study conducted by McDonagh et al. (2005). The study established that nearly 90 percent of adult patients are victims of childhood neglect and abuse. The supporters of this theory believe that detachment between the child and guardian results to a disturbance between the youngster’s capacity to incorporate lifetime events or occurrences (American Psychiatric Association, 2000, p. 5).
It has been suggested that in the long run such situations can bring about neurobiological transformations. This facilitates the development of particular personality, each with varying cognizance of their encounters (Forrest, 2001, p. 276).
According to the American Psychiatric Association (2013, p. 30), DID is characterized by: exposure to painful experiences, steady evasion of jolts connected with the occasion, and indications of increased hyper-excitement never displayed before. Moreover, the manifestations ought to last over a month and can cause some form of mental disability. Recent studies have identified two types of patients suffering from posttraumatic stress disorder.
These studies show that some patients exhibit dissociative symptoms and non-dissociative symptoms. Patients exhibiting non-dissociative symptoms often react to trauma cues exceedingly. However, patients with dissociative symptom normally react to trauma cues less vigorously (Dalenberg & Carlson, 2012, p. 59).
Dissociative patients often react like an animal that has surrendered due to some form of impairment or disability. However, it should be noted that patients suffering from posttraumatic stress disorders can exhibit both dissociative and non-dissociative symptoms (Dalenberg & Carlson, 2012, p. 59). Nonetheless, studies show that protracted traumatic experiences, for instance, extreme childhood maltreatment or trauma as a result of war, are always linked to dissociative reactions, which may lead to dissociative identity disorder. Extreme and protracted traumatic experiences can also be associated with hyper-reactions to reminders of traumatic events (McDonagh, 2005, p. 516).
Studies show that all individuals must experience at least one traumatic experience in their lifetime. Roughly 20 percent of these individuals often develop posttraumatic stress disorder (Forrest, 2001, p. 280). The kind of trauma normally linked to posttraumatic stress disorder includes exposure to acts of violence, rape and sexual abuse (McDonagh, 2005, p. 517). Whereas most people are able to cope with such experiences, some of them normally fail to recover. Mental experts link it to genetic and environmental factors (Forrest, 2001, p. 282).
The non-trauma linked theory is based on the viewpoints that do not link DID to childhood distress. This includes the iatrogenic, socio-cognitive and fantasy theory (Dalenberg et al., 2012; Spanos, 1996). The supporters of this theory believe that authentic instances of DID are imaginary and stresses that the signs DID are deliberately or inadvertently carried out by the victim as a result of unsuitable treatment methods and sociocultural forces (Dalenberg & Carlson, 2012, p. 553). The iatrogenic theory focuses on the role of psychotherapy in drawing out the signs linked to the examination of DID (Dalenberg & Carlson, 2012, p. 555).
From this perspective, an exceptional bond between the psychotherapist and DID patient can cause a cognizant reenactment of diverse character states by the patient so as to delight and persuade the psychotherapist. Advocates of the iatrogenic theory also accept that sham recollections of childhood mistreatment may be made-up in highly susceptible people (Zittel & Westen, 2005, p. 870). Extreme susceptibility and fantasy inclination can be a major factor in the efficiency of constructing individual personalities (Merskey, 1992). This viewpoint is upheld by reports that numerous patients do not expressly demonstrate alternating identity states until they start their treatment (Ross & Ness, 2010, p. 463).
In view of the socio-cognitive theory (Spanos, 1996), social and cultural variables, for example, general exposure of DID incidences and successive depiction of this disorder in the press, movies and books can contribute to falsification of DID (Ross & Ness, 2010, p. 464). Backing this idea is the finding that increased portrayal of DID in the European and American press is highly linked to the fictitious cases of DID (Merskey, 1992).
Pope et al. (2006) tracked the interest of the media and scientists as regards DID from 1984 to 2003. Their study took into consideration the number of publications in each year. Whereas the rate of publication for entrenched diagnoses, for instance, alcoholism and Schizophrenia consistently increased, diagnoses for dissociative amnesia and dissociative identity disorder declined each year.
However, the study was criticized by the supporters of trauma-linked theory. They argued that the study had a number of methodological shortfalls. For instance, the study did not take into account literatures that link DID to trauma-related experiences (Dalenberg & Carlson, 2012, p. 557). Moreover, some of the recent studies, for example, a study conducted by Boysen and Vanbergen (2013, p. 7) confirm that the publications were lower than the reports released by the medical practitioners regarding mental disorders.
The role of imagination inclination has as of late been explored in two independent studies: in the first study, Dalenberg et al. (2012) examined the correlation between pathological disconnection, distress and fantasy aptness. The principal objective of this study was to examine two theories based on the existing research, that is, the trauma-linked theory and the fantasy theory. They reported that trauma-linked theory is dependable in both clinical and group tests and that it has a comparable impact on ideal studies. Similarly, the trauma-linked theory was discovered to be steady in the short-term except for situations where treatment is provided.
Moreover, dissociation and childhood distress were found to be related. Even though fantasy inclination was found to be regulated, separation is not dependably connected with suggestibility, which was normal taking into account the fancy theory.
Dalenberg et al. (2012) also found that dissociation is identified with disintegration and is severe in DID patients. They also found that dissociation is highly associated with individuals with childhood mistreatment. In addition, Dalenberg et al. (2012) also links disassociation to past experiences, especially during childhood. Nonetheless, studies that link DID to psychological distress are still lacking enough evidence. This shows that dissociation is related to new ideas, desire or imagination and, therefore, non-trauma-linked theory does not apply.
Diagnosing the Disorder
DID patients are very poly-symptomatic and large number of them have comorbid psychological problems (Grilo, 2005, p. 80; Gleaves, 1996, p. 44; American Psychiatric Association, 2013, p. 32; Blueford, 2013, p. 100; Ross & Ness, 2010, p. 463). These elements alongside doubts or insufficient information by psychiatrists are the fundamental reasons why DID is often overlooked or misdiagnosed (Ross & Ness, 2010, p. 465). In most cases, DID patient do receive a completely different diagnosis and therapy because of the above reasons prior to getting the right diagnosis and psychotherapy (American Psychiatric Association, 2013, p. 33).
Some of the most common symptoms of DID is total or partial loss of memory. Patients suffering from DID more often than not are not able to remember very significant individual information, which is considered to be too broad to be clarified by common lack of memory (McDonagh, 2005, p. 516; Grilo, 2005, p. 77; Gleaves, 1996, p. 44). This is normally referred to as dissociative amnesia (American Psychiatric Association, 2000, p. 6).
However, the most significant sign of DID is the presence of two or more personality states. Each state has its own way of understanding, identifying with and contemplating nature and self with no less than two of the characters or identity states intermittently taking control of the individual’s conduct (American Psychiatric Association, 2000, p. 5; Dorahy et al., 2004, p. 93; McFadden, 2011, p. 58). These symptoms may appear as a result of the psychosomatic effect of drugs (for example, alcohol or illegal substances), a medical condition (for instance, epilepsy) or during extreme imagination as in the case of children (American Psychiatric Association, 2000, p. 7). Other characteristics of DID include completely different identity, de-realization, and nervous dissociative signs (Dorahy et al., 2004, p. 94).
A study by Zittel and Westen (2005) reported that many patients suffering from dissociative identity disorder also suffer from borderline personality disorder, commonly known as posttraumatic stress disorder. What is more, the study revealed that patients with dissociative identity disorder must have previously suffered from Schizophrenia. Nonetheless, there is a high probability that this finding signifies an erroneous diagnosis rather than comorbidity. This is because patients suffering from both schizophrenia and dissociative identity disorders also exhibit symptoms of the schneiderian disorder (Grilo, 2005, p. 79; Gleaves, 1996, p. 45).
In addition, other symptoms of comorbid disorder are potentially caused by an organic mental disorder, psychotic disorders, personality disorders, somatoform disorders, eating disorders, drug abuse, and anxiety and mood disorders (Grilo, 2005, p. 80). American Psychiatric Association (2013, p. 65) also stresses that a combination of somatoform and conversion disorders can result in comorbid disorder. Although the symptoms of dissociative identity disorders are multifaceted, diagnosis and treatment of the disorder are further convoluted by the presence of additional symptoms.
The nature and diagnosis of the untreated dissociative identity disorder remain unclear. Furthermore, diagnosis is complicated further when patients suffer from comorbid disorder (American Psychiatric Association, 2013, p. 32). It is important to note that there are a number of factors that inhibit effective diagnosis of dissociative identity disorder. These include: defiant identity, dietary problems, substance misuse, taking part in unlawful exercises, and staying in an oppressive environment. In spite of the fact that many people show symptoms of dissociative identity disorder in their adulthood or late adolescence, the mean age at which DID diagnosis occurs is roughly 30.
However, the majority of the DID prognosis are carried out between 5 and 10 years after the symptoms have already emerged (Blueford, 2013, p. 103; Ross & Ness, 2010, p. 461). According to Forrest (2001, p. 272), a risk factor entails having first-degree relatives who have undergone prognosis of dissociative identity disorder.
Risk Factors and Prevalence of DID
A study by McDonagh et al. (2005, p. 517) reported that a child is seven times at risk of suffering from a dissociative disorder if he/she was exposed to a traumatic experience. Subsequent prognosis of dissociative disorder revealed that a child is two times at risk of experiencing disruptive disorder if his/her mother suffered from trauma within two years of the child’s birth. In another study, McFadden (2011, p. 59) stated that over 95 percent of child abuse cases resulted in dissociative identity disorder among children.
Nevertheless, prior history of child abuse is not the only cause of dissociative identity disorder among children. Other factors that contribute to dissociative identity disorder include disoriented or disorderly attachment lifestyle, as well as absence of familial or social support (McFadden, 2011, p. 59).
Culture is also another contributing or risk factor. A study conducted by Dalenberg and Carlson (2012) found high prevalence levels in Turkey, Norway, Netherlands, Canada and the United States. On the contrary, the study found low prevalence levels in Japan, Germany and India. In another study, Xiao et al. (2006) sought to establish the prevalence rates of DID among the inpatients, outpatients and the general population in China. The results of his study revealed a prevalence level of 0.5, 0.3 and 0.0 for the three categories in that order.
Furthermore, the prevalence and etiology of DID are attributed to those factors associated with collective and individual cultures. For instance, Fujii et al. (1998) also reported that the prevalence of DID in Japan was lower compared to that in the United States and attributed these differences to cultural factors. His findings revealed that the majority of American participants suffering from DID must have experienced either sexual or physical abuse during their childhood. On the contrary, Japanese participants suffering from dissociative identity disorder had experienced fewer incidences of sexual or physical abuse during their childhood. In addition, the researchers reported that the American participants had approximately three times as many personality states compared to their Japanese counterparts.
Treatment of Dissociative Identity Disorder
While the ultimate aim of treating DID is to synchronize the functioning of the alter personalities, the existence of comorbid disorders, traumatic experience and issues regarding the safety of patients makes an all-inclusive treatment plan necessary (International Society for the Study of Trauma and Dissociation, 2011, p. 115). The International Society for the Study of Trauma and Dissociation (2011, p. 159) issued a number of elementary instructions to help therapist in treating dissociative identity disorder. The framework used in treating DID include:
- stabilization and symptom reduction,
- working directly and in depth with traumatic memories,
- identify integration and rehabilitation.
Although these phases are administered during the treatment phase, they define the major therapeutic issues that emerge during the phase of treatment. As noted earlier, a traumatic event can result in intense emotions. Therefore, people suffering from dissociative identity disorder are likely to behave in a way that may cause harm to themselves and others. As a result, the treatment should entail strategies of managing violent behaviors among people with dissociative identity disorder.
In addition, behavioral or cognitive therapy should be administered to help the victims learn how to control their impulses (International Society for the Study of Trauma and Dissociation, 2011, p. 161).
Therapists must also understand that some patients are not willing to synchronize their personalities. If this happens, the therapists should not consider different personality states as a problem to be alleviated, but as a positive reaction of a patient to trauma (International Society for the Study of Trauma and Dissociation, 2011, p. 161). One of the best strategy for treating dissociative identity disorder is to recognize relationships between alters and communicating with them directly. Therapists must also encourage the patients to listen to their personalities in order to facilitate essential conversation among alters and the victim (International Society for the Study of Trauma and Dissociation, 2011, p. 162).
DID is still a mystery to mental health experts. No wonder, there is still no common ground as regards its diagnosis and therapy. However, one thing that is clear is that DID is linked to past or present traumatic events. Its common characteristics include the presence of two or more personality states and partial or total loss of memory. DID may be provoked by drugs, medical conditions or extreme imagination as in the case of children. Many patients suffering from dissociative identity disorder also suffer from borderline personality disorder, commonly known as posttraumatic stress disorder. Studies also show that patients suffering from dissociative identity disorder must have previously suffered from Schizophrenia. All in all, DID is still a work in progress.
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